Okay. Welcome, everybody. Welcome to today's AOAAM webinar, Xylazine Wound Care Clinic and Protocol by Ms. Rachel McFadden, MPH, VSN, RN, and CEN. My name is Julie Kmik and I'm going to be your moderator for this session. This is the first of our summer webinars on hot topics in the treatment of opioid use disorder and stimulant use disorders. So welcome, everybody. I'm glad to have you back for this series. I'd like to tell you a little bit about our speaker. Rachel McFadden, MPH, RN, CEN, is a nurse at the Hospital of the University of Pennsylvania Emergency Department and at Prevention Point Philadelphia's Wound Care Clinic. The foundation of our clinical philosophy and practice is harm reduction, a social justice movement, as well as a practical approach to reducing the negative consequences of substance use. As a Bloomberg Fellow at the Johns Hopkins School of Public Health, her work centers on reducing stigma and strengthening healthcare's capacity to respond to the opioid slash substance use crisis through the integration of harm reduction while bridging medical services to community-based and public health efforts. For this presentation, we're going to be holding questions until the end. You can enter them in the Q&A box and we'll get them answered after the presentation. I'm now going to turn it over to Ms. McFadden. Welcome. Thank you so much, Dr. Kamek. It's really an honor to be here. No funding disclosures for me. I will say that I received verbal informed consent to show the photos that I will show of some wounds. And then I mentioned some brand names of wound care supplies because it's easier to talk about wound care that way, but not because I formally endorse or disapprove of any products. So I work, I'm a nurse in the emergency department at the Hospital of the University of Pennsylvania. But the story about wound care that I'm telling today is really coming from Prevention Point, Philadelphia's wound care clinic. And it starts with the unregulated drug supply in our region, which is behind this and so many other harms that people face. But our clinic has really evolved around and to try to address some of these harms. Then I'll talk more about kind of what we know about xylosine-associated wounds and demonstrate a standardized approach to assessing and treating them that can be applied in pretty much any setting. And then I'll talk through a few hospital and harm reduction specific considerations that are pertinent to wound care for people who use drugs. So the Prevention Point clinic is where I have learned the vast majority of what I know about this. It's a wound care clinic specifically for people who use drugs that happen to be situated in the center of what we, you know, now is the xylosine epidemic. And we've known forever that people who inject drugs are at high risk of skin and soft tissue infections, and that they don't often access care in traditional healthcare settings. So in the 20 teens in Philly, there was this huge encampment of unhoused folks, mostly people who were using drugs and accessing their supply from Kensington's open-air drug market. There was a nurse at that time, Sheila Dand, who's pictured, who was working at Prevention Point and decided to start showing up at this encampment in a mobile van to provide wound care to these people who weren't getting wound care pretty much anywhere else. They worked, operated mobily for a couple years until the city forcibly displaced the people in this encampment, which led to the creation of smaller and more scattered encampments. And so the van changed locations over the years, although it became increasingly difficult to meet people where they were as these encampments continued to be dispersed. Then when COVID hit in 2020, our clinic transitioned from mobile to brick and mortar and developed a much stronger relationship with the Prevention Point syringe exchange. And this was intended to be a temporary change, but it actually made a lot of sense. It allowed for a kind of centralized location where participants could reach us, and it helped participants be able to access services beyond the wound clinic as well, other services in the building. So that's where we have remained. And a few specifics about our operations, because we are kind of a special clinic. The main thing is that we try to maintain a very low barrier operation. So it's walk-in, it's free, we don't require insurance. We expect that our patients who have substance use disorder will be using substances so that they will show up in various stages of intoxication or withdrawal. And we also partner with a local pharmacy to stock a lot of the commonly used medications in the clinic so that people don't have to make another stop in their care if they need antibiotics or ibuprofen, things like that. We are a nurse-led clinic. So we have a small number of paid nurses and a few volunteers. In the top photo with me, you can see Christy Petrillo, who's our full-time nurse practitioner and clinic coordinator. But we partner with some really wonderful providers from Temple University who help a lot with hospital referrals when that elevated level of care is needed. And I'm kind of spotlighting Dr. Megan Healy from emergency medicine and Dr. Brian Work, who's a hospitalist on the addiction care team there, who have been some of our biggest champions. I'm assuming that this group is pretty familiar with the story of xylosine, but I'm just going to layer onto that our experience on the ground from the clinic. So there has been a small amount of xylosine in the unregulated drug supply in Philly for a long time. But at the end of 2019, we started hearing from our patients in clinic, so people using the Philly drug supply every day, that the amount of xylosine in the fentanyl had skyrocketed. They were kind of encountering it in a lot more of the supply that they were using. So that was 2019 people first started talking about this on the street. By the time the Philly public health department starts testing the fentanyl in 2021, it was already in up to 90% of that illicit fentanyl. And then by last year, it was in essentially 100% of the fentanyl. And we of course believe it was added to the supply as a potency enhancing agent to kind of smooth out the withdrawal redose rollercoaster that people find themselves on with fentanyl. Although it was then and continues to be largely undesired by people who use drugs, they don't overall like the effects of xylosine. One of the reasons being the wounds. So xylosine at this volume, or the volume that we're seeing now is new, but the substance itself is familiar to communities of people who use drugs. And again, I'm sure many folks here are familiar with kind of this part of the history starting back in Puerto Rico. But what I like to emphasize is that in the early 2000s, in these first published reports on xylosine coming from Puerto Rican communities, both on the island and in New York City, these reports are describing exactly the kinds of wounds and kind of compounded dehumanization that people are facing today. And at the top of the screen here is I think a particularly powerful report by Rafael Tarula on this. Now, again, it's in nearly 100% of the illicit fentanyl and phylline. We continue to be kind of the epicenter of tranq dope. But people all over the country are starting to find xylosine in their fentanyl supply as well. And it's, you know, xylosine is getting a lot of attention right now. It's implicated in some pretty big issues, but probably the biggest harbinger of this attention is the visibility of chronic exposure in the form of wounds. And colloquially, we call these tranq wounds. And the causal relation between xylosine and wounds is not uncontested. We don't know a whole lot about it. And there are people who believe that they are not, you know, necessarily associated. And this diverse thought I think is healthy. It's going to drive further kind of learning and investigation into what's going on. I personally am in the xylosine-associated wound camp. And so I'm going to speak from that perspective. And then I have here pictured on the left or on the right, Brooke. So Brooke was one of the first people I met, I knew, who developed a tranq wound. And we spent a lot of time together in the wound care clinic. And they ultimately required an amputation due to its progression and passed away earlier this year from complications from their wounds. And my goal is to take what people like Brooke had to learn, what we learned in the clinic, and what we're now learning in our hospitals, and pass some of that on to really inspire hope in the people that you may be working with and meet who are struggling with these wounds. So diving into the wounds themselves, and this is where the photos start. And I'll say, you know, for my, I know this is a group of clinicians. I love wound care. I do not love disembodied photos and wounds. So I've tried to be judicious in their use, but just a heads up. So we don't have great data on kind of prevalence yet. But I'm showing on two levels, the increase in skin and soft tissue injuries among people who use drugs since xylosine began to predominate in the unregulated drug supply. So at the wound care clinic, Prevention Point Wound Clinic, in 2022, we clocked five times the number of visits as we did in 2019. So pretty significant, and boy, did we feel that growth in volume. And this is mirrored in city level data on ED visits for skin and soft tissue injuries among folks with a diagnosed substance use disorder. So we see a bit of a bump in the rate in 2020, obviously confounded by COVID. But then in 2021, we really start to see the climb. And I'm confident that has continued through to the present. I'm seeing this in the emergency department so much more now than ever before. There have been a smattering of cases and case series on these wounds in the published literature. Most of them happen to be out of Philadelphia. What they all basically say is that by the time people show up for care at a hospital, their wounds are severely progressed. And their prognosis is complicated by things like HIV and hepatitis C, as well as active fentanyl dependence with xylosine exposure, as well as difficulty staying in the hospital for care due to pain and withdrawal, and that they lack access to the really fundamental social determinants of health. So people are often unhoused and have really limited socioeconomic supports. In the center is depicted some of the most common locations we are finding these wounds. And this anatomical figure is based on a case series of about 60 wounds among hospital patients who tested positive for xylosine and presented for a wound-related issue. So you can see mostly we're looking at the extensor surfaces of the four extremities, although there have been more anomalous cases as well involving the chest and supraclavicular fossa and other areas as well. Now, in the old days, these were the kinds of skin and soft tissue injuries that we most often saw among people using drugs. So these are injection-related infections like cellulitis and abscesses and rarely neck fash. These are all infections, and most classically they occur following a penetration of the skin barrier by a needle, which introduces bacteria, and you get a bacterial infection in the soft tissue. We still see those things, but compare that to what we're seeing now. So I'm going to highlight a few things that I think are kind of hallmarks of these wounds. So first, they aren't infectious in nature. They start as soft tissue necrosis, and they progress through further devitalization and erosion. They tend to be loaded with this devitalized tissue like slough and eschar, but overall can also be kind of mixed wound beds, and this photo is a good example of the kind of commingling of granulation tissue with this devitalized tissue. The two forms of necrotic tissue are eschar, which is the tough black adherent stuff, and then slough, which is yellow, soft, and kind of mucinous tissue. But all of this devitalized tissue blocks regranulation and healing and also harbors a ton of bacteria, and I'm going to talk more about the kind of noxious biofilms that form on these wounds. Next, they are almost invariably full thickness, and not after weeks, but very early on, like often from the start, and I'll talk more about why that might be. But the full depth can also kind of be obstructed by this overlay of eschar and slough, but it's not uncommon to discover exposed bone and tendon once this devitalized tissue kind of pulls away. These wounds drain a lot, and they're often high surface area wounds, so we would expect this. You think about the insentient fluid losses we worry about with large burns, and the drainage picks up a pretty strong odor from all that necrotic tissue and bioburden, and though it might appear kind of yellow, green, or brown, that's usually the necrotic tissue itself kind of sloughing away. It's not purulent drainage, indicative of an acute infection, and the drainage is relevant because it compromises surrounding tissue if not well managed and is a huge contributor to wound expansion, but also because of the immense distress and social alienation that it causes for people. And then finally, very often, and again, almost invariably, I'd say these wounds progress into complex wounds, and you can kind of see the description of a complex wound on the table there. It's a classification similar to chronic wounds, but without the time frame criteria, which is important in this case, and including important extrinsic factors that impair normal healing. So for example, ongoing xylosine exposure or the lack of social determinants of health. So these are wounds that get stuck in this inflammatory kind of state of healing. They're very tricky to manage, as chronic wounds are. And an important side note, what we know about complex wounds is that they often require expedited surgical intervention because our more kind of traditional conservative treatments generally fail unless the complex conditions of the wound change, and therefore they need that expedited surgical intervention. In terms of, this is coming back to biofilms. So biofilms are a tricky thing and can seem kind of hard to assess for with your naked eye in the wound, but they are known to be just part of a complex or chronic wound and really, really inhibit healing. So you basically take planktonic bacteria, they form these colonies with a protective shield around them. They become kind of dormant in those colonies, but then they can spread all throughout the wound. And they're important because they both can cause acute infection in a chronic wound, but they're also not really penetrated by systemic antibiotics or not at all. And that's both because of their protective coating and because most antibiotics target metabolically active bacteria. And they're highly, highly pro-inflammatory. So this contributes to stalled healing, as well as adding a lot of just kind of noxious bio-burden to the wound itself. And I'm coming back to this later in the presentation when we talk about the wound care itself. But in order to disrupt these biofilms, you need both a topical antimicrobial and debridement, which is really important kind of keys to caring for these wounds. Now, in terms of the how, there's still a lot to be, a lot of work to be done to truly understand what's happening here. And again, some people question the connection at all, but we do know that xylosine exerts both local and systemic effects that could plausibly lead to soft tissue necrosis. The researchers in Puerto Rico back in the 2000s really tried to dig in this. They wanted to find the mechanism behind what they were seeing happen in a community of people that were being chronically exposed to xylosine. Everything else in the literature up to that point was kind of single use in animals or exposure in humans. So we're talking now about chronic exposure to xylosine. And they identify direct cytotoxicity in the soft tissue caused by xylosine, especially in the kind of unpharmaceutical, unregulated doses and potency that people are exposed to in the unregulated drug supply. But additionally, we think that there's also some vasoconstriction. There's the alpha-2 agonist-related hypointension in bradycardia. In the limited biopsy data that we have, we know that there's some vasculopathy that occurs too. And all of these effects are compounded by the toxic effects of other substances like illicit fentanyl and cocaine, which we know is often in the supply as well. So what we can say with certainty is that the hallmark of these wounds is necrosis. So they start as necrotic tissue and they progress through further necrosis. And there are plausibly some ways in which xylosine is doing that, both systemically and locally. And I want to propose a sort of parallel to deep tissue injuries here, wherein the injury starts below the surface in the hypodermis. And this is kind of like the textbook description of the formation of a deep tissue injury, a DTI. So it's caused by compromised perfusion leading to ischemia of the deeper tissue layers, soft tissue layers. That ischemic tissue, as it dies, pulls away from the epidermis, which causes this blister-like skin defect. And within a couple days, you have this dark purple boggy area. So it's already full thickness at this point. It's already a full thickness wound. It just hasn't unroofed. And in the case of a DTI, this necrotic boggy tissue often transforms directly into a sort of desiccated shield of eschar covering that full thickness depth of the wound. Down to the timeframe, that description is almost verbatim how I would describe the evolution of a xylosine wound. And I'm focusing on wounds that develop at the site of injection drug use because they seem to progress faster and into more severe states, but I'll revisit wounds in the cases, you know, outside of injection drug use later. So here you can see that early phase at the site of an injection, that deep irregularly bordered dark purple blister. So that's the site of ischemic tissue in the hypodermis starting to pull away from the epidermis. And we see these blisters in isolation or around existent wounds, which is what I'm showing here in that white oval. And then eventually, usually within a week, that purple blister seems to transform directly into the shield of adherent eschar and or on roofs to reveal the full thickness of the wound. Here are a couple more photos of those early phases. So in the left and center, this dark purple blistering, that ischemic tissue starting to pull away, which then evolve into this thick adherent eschar over a full thickness wound bed. And there are several conditions that usher these wounds, you know, beyond that into a complex state, like the lack of social determinants of health and the presence of comorbidities in addition to continued exposure to xylosine and other substances. But chronic complex wounds are really different from acute wounds and much more challenging to treat. A lot of it has to do with that biofilm and being stuck in a hyperinflammatory state. And this is important because it informs our decisions about how to treat this wound, both topically and if we need to surgically. So that was all focused on the injection of xylosine. And injection, again, does seem to lead to the more severe of the wounds that we see. But as you may have seen or heard, wounds can also develop away or distant from sites of injection and when xylosine is consumed via other modes, so smoking or snorting. And something that we're seeing quite often now is that a wound with a totally different ideology, so a burn or a laceration or a bug bite can progress into a wound that kind of has all the features of a xylosine wound. And it's important to note because it really hammers home that this isn't just about injection drug use, but it actually seems to be the substance itself, the xylosine, which causes harm above and beyond the way people are actually using it. And wounds not at injection sites are often these kind of coin size, smaller ulcerations with this friable cap of devitalized tissue can look like a cigarette burn. And then occasionally we see these larger, almost abrasion looking surface wounds. Now, coming back to progression, I have this nice photo series here, very generously shared by a Prevention Point wound care patient. And I'm gonna use it mostly for the ending. So this is just a review of the initial blister stage and then what many people call the chemical burn phase, so when these blisters start to coalesce and transform into eschar, then the amount of devitalized tissue and particularly eschar that can make it really difficult to know how deep some of these progressed wounds are. It is very possible that the wound has eroded down to deeper structures like tendon and bone. And of course, the most severe wounds will cause erosion to these structures as well, which can cause loss of sensory and motor function just to the wound. And this is when folks end up being told they'll need to lose that limb. But, and this is so important, healing is possible. So this is the same young woman whose pictures I was just showing, who we treated in clinic. She had one surgical debridement and the rest she did on her own using topical treatment approaches or topical treatments and approaches that I'll talk about later, really did a phenomenal job healing both of her wounds to completion. And you might look at those scars and think, gosh, they still look pretty rough. But I just wanna take a moment to read this really beautiful quote from another clinic participant, Tracy McCann, who was interviewed by the New York Times about her experience. So from wrist to elbow, her meandering pink and purple scars are a roadmap of being lost and found. People out here might think my arms look really ugly, but they aren't familiar with tranq wounds yet, she says. To me, my arms look really beautiful now. And it's hard for me not to even get a little emotional just reading that, but healing is possible, including while people are still using and we really need to tell people that. So I'm gonna transition into talking about, what do we do about these wounds? What's kind of a good approach? And this is a kind of age old wound mnemonic that I've adjusted a little bit to talk about these wounds, but it is really effective and you really can't go wrong using this approach in any setting. And it's called DIME. So D is for debridement, so removing that necrotic tissue. I is for infection or inflammation. We are assessing for and treating both of those things. M for moisture, which is really all about striking a balance. And then E, edges, so protecting the peri wound and protecting the intact tissue around the wound to minimize expansion. And I'll kind of dissect each of these now. So starting with debridement, so you're assessing for devitalized tissue. And if your assessment is you've got devitalized tissue, your intervention is going to be to get rid of that, to debride it. And there are several ways to do this. One is through autolytic debridement. So using topicals, which really just optimize the wound environment to harness the body's natural capacity to dissolve dead tissue, which it is very good at and doing it a highly selective way. And I've highlighted this one here because it's what we're really capitalizing on with these wounds. It is gradual, it's painless, it uses fairly inexpensive products and can be done in any setting from the home to the hospital. Enzymatic debridement is a thing. Using Santol is an option, but Santol does not penetrate intact eschar. So looking at this wound, it's probably not going to work on about at least like 30% of this wound. And it is also outrageously expensive. And there are certainly times when the burden of devitalized tissue is particularly bad, which is an indication for surgical debridement. And as I mentioned with complex wounds, we often need to do that sooner than we do in order to disrupt the biofilm and get rid of that necrotic tissue. And that's just physically cutting away the dead tissue. Then we're going to look at infection and inflammation. And the take-home here is whether or not we find local infection, we're going to assume that high bio-burden and inflammation and treat that. And of course, there are the classic signs of local infection, although these can be confounded in chronic wounds and by things we expect to see even in a non-infected xylosine wound. So for instance, I mentioned that drainage picks up a lot of odor and necrotic tissue as it comes away. So it can look purulent even though it's really not. So what we really focus on in the clinic and in the hospital increasingly so is surrounding erythema and swelling. So is there gross swelling of the limb or at least the area around the wound and then that bright red kind of cellulitic look around the wound. We do certainly get worried about infection in the deeper structures. The longer these wounds are present. So osteomyelitis and tenosynovitis. And there are specific bugs we might see colonizing and potentially infecting these wounds among folks who inject drugs and who may spend a lot of time outside. So MRSA and Strep A are some big ones which may influence our choice of antibiotics. We're also seeing a good deal of Pseudomonas in Kensington which we know to be prevalent in environmentally exposed wounds but really hasn't been written about in this context. This is just reinforcement. Again, you can tell this is something I think is really important. If your assessment reveals devitalized tissue you can be confident that biofilm is present. And so regardless of your decision to use systemic antibiotics, we've got to put some kind of antimicrobial in the wound bed together with a plan for debridement to disrupt that biofilm. So M for moisture and this is really about balance. So we need moisture in the wound bed. That is what helps create an optimal environment for healing and helps facilitate autolytic debridement. But we need that moisture absorbed by a dressing while protecting the skin around from becoming macerated. You definitely don't want wounds drying out. Although people often do this because the drainage is a source of such distress, the smell and the amount of it which really causes a lot of social alienation and shame. But we can help build a good dressing that helps strike this balance as well as providing some education to people about the importance of balance. And then last but not least, these edges, the edges of the periwound. So protecting the periwound is preventing wound expansion. It can take a day for the wound to expand a few millimeters or up to a centimeter and weeks, weeks, weeks, or months to heal that. So we help this protection by applying ointments to protect the periwound and building a dressing that keeps that wound exudate off the intact tissue. We talk about behaviors that are compromising the periwound as well. So I have this snapshot of the Harm Reduction Coalition's called Getting Off Right, which is a sort of textbook of safe injection practices. And traditional harm reduction wisdom says alternate injection sites, but it is not so straightforward in the era of tranq wounds now. And I'll talk more about this, but having frank conversations about the risks and benefits of using other sites, whether it's the wound itself or other locations on the body for people who are not able to stop injecting, having those frank conversations to help people make the safer and more informed decision helps us also remain informed about how people are making decisions and kind of coming up with individual harm reduction strategies. So I'll zero in a bit now to the dressing itself. So how to build a good dressing. And this is not quite first aid wound care. There's a little bit more to it, but it's not rocket science either. So here's what I call the anatomy of a good dressing. So we've got the wound bed, which are going to clean and apply a treatment topical to. In this case, we want that topical to be both antimicrobial and to facilitate autolytic debridement. We're also gonna apply some topical to the peri-wound area for protection. Then we've got a primary dressing. The primary dressing is our contact layer and its job is to be non-occlusive, so to allow that drainage to pass through it and non-adherent, so not stick to the wound bed. Then a secondary dressing, which is our absorbent and kind of cushioning layer followed by some kind of securement. And I'll now introduce some supplies that we at the clinic have found particularly helpful when dressing xylosine wounds. So cleaning is obviously important and it's always great to start with just plain old water or normal saline to kind of get the larger particulate matter off. But because of that biofilm, it's best to do a sort of enhanced cleansing using some sort of chlorine-based antiseptics. And any of these products are very well tolerated, even in folks with opioid-induced hyperalgesia, although doing a spot check is always a good idea. But they help to reduce bio-burden, they help to reduce odor, and they can also help maintain a nice moist wound bed, which is gonna help support debridement. Generally speaking, you just saturate the wound with your solution of choice and let it dwell for about five minutes before moving on to the next part of your dressing. We use a lot of VOSH and antisept in particular in the clinic because they are not prescription. You can just order them through many medical supply companies. These are a couple topicals, specifically for the peri-wound. Remember, this is a whole letter, a whole one quarter of your dime approach, so really important. The People's Choice Awards go to A&D Ointment and Triad. They're both very soothing and protective. You can color outside or inside the lines with both of these, so they're totally safe to use in the wound. In fact, some people prefer to use them exclusively in their wound. And in their wounds, and that's okay. In addition to preventing maceration, and triad in particular is really, really helpful when people have highly exudative wounds, they also provide a lot of relief for the kind of itching and burning discomfort that many people experience around their wounds. When it comes to the wound bed, so I mentioned autolytic debridement is what we're capitalizing on. We've got several ointments that do this while also serving as an antimicrobial to disrupt that biofilm. So Meta Honey, I think people are the most familiar with. It's also pretty widely available. It feels nice, it smells nice while preventing bacterial growth and creating kind of the perfect environment for healing. However, in the clinic, we refer to this product as seasonal because people who are unhoused have trouble with it in the warm months. It does attract insects. So we are not using a lot of Meta Honey right now at prevention point. Silver products. So we've got sulfur, sulfadiazine, silver gels, silver alginates is most of what we use in the clinic these days, even when it's not warm out. It does a wonderful job debreeding. It can really help chew through all that eschar and slough and biofilm. And it is really packs an antimicrobial punch. So it's a broad spectrum antimicrobial. The Temple Burn team is hopefully gonna be publishing some data on using this product in xylosine-associated wounds in the near future. So you can look out for that. But we've kind of been working with them to adopt this as almost a standard within our practice. But we do also use PHMB, which is not quite as available as silver, but similarly useful in terms of broad spectrum coverage and supporting autolytic debridement. And all of these are very well tolerated in my experience, no burning or irritation. But again, doing spot checks is always a good way to kind of build rapport and just to be sure. Now I'm showing these because they exist, but we rarely use them. Santol, I mentioned, doesn't penetrate intact eschar. It's so expensive. And then antibiotic ointments, because there are concerns about resistance, especially around mupiricin, and they don't really support autolytic debridement in the same way as some of those on the previous slide. So then next is the primary dressing. This is what sticks directly onto the wound. So the most important thing here is that it does not stick. If you've ever watched someone peel a stuck dressing off their wound, it's bad. And when that person is maybe in withdrawal and also has opioid-induced hyperalgesia, it's pretty much unbearable. So we can prevent that by using one of these. And oil emulsion dressings like Adaptic are really wonderful because you can apply your topical directly onto that dressing and then kind of fit it, place it onto the wound. So you're not even touching the wound itself. It also is non-occlusive. So it allows drainage to pass through, which is good when you have high output wounds and you don't want that drainage pooling inside, you want it to pass through into your absorptive secondary dressing. Petroleum-based primary dressings are out there and they're often used in the hospitals, but they are occlusive. So you're gonna have different issues kind of managing drainage with these. And then with Alginate and Aquacel, they come out of the packaging dry, but they convert to a gel in the wound. They're exceptionally absorbent, which is great. And you can also get them imbued with things like silver and metahoney. So you're actually kind of getting a three for one with these. Autolytic debridement, antimicrobial, absorbency, but they are expensive and functionally just aren't great for people who are unstably housed. So we don't end up using these very often in the clinic. Now, the secondary dressing, we most often just use plain old ABD pads. They're really nice because they absorb a lot and they kind of cushion, which is especially good on arms and legs that are kind of banging into things all the time. You build a sort of pillow over that very exposed to tender wound. But the most important thing about the secondary dressing is that you can change this dressing while leaving the primary dressing intact. And this is a great trick to help manage high output wounds. So reduce the distress that comes from drainage and odor while preserving supplies and avoiding the trickiest part of the dressing change, which is fully exposing the wound. So if I do a fresh dressing in the morning and by 1 p.m. that outer layer, that secondary layer is saturated, I can just peel away that secondary layer, leaving the primary layer and all those topicals in place and just apply another ABD and some wrap. So it's really a great way for people to help kind of manage their drainage while not having to do a full dressing change. And then lastly, you wanna put some kind of securement around the whole thing. So roll gauze is an obviously great option, but then applying an ace wrap or a tuba grip or coban, so things that keep the dressing from sliding around. Ace wraps are particularly great because you can reuse them, but with all of this, it's important not to apply compression. These are just to hold things in place, not to compression. So just a little exercise to kind of put this all together. Someone shows up at your clinic or your place of work and they show you this, what are you gonna do? Don't run away, just use DIME. So D, debridement, we've got a lot of dead tissue here that we need to debride. There's no real obvious local infection going on here, but certainly evidence of biofilm and inflammation. And then heavy exudate, we can see some evidence of maceration at the peri-wound area. So we're gonna wanna address those issues too. We can use metahoney to do our debriding and to help reduce the bio-burden in the wound. We can also use VOSH, which is gonna help that bio-burden and reduce odor. The peri-wound that looks kind of irritated and a bit macerated, we'll apply some Triad too. And we'll apply our metahoney to an Adaptic, which is gonna be our primary dressing with a layer of ABD pads to absorb all that drainage and keep it off the peri-wound tissue, and then some Curlex and TubaGrip to hold it all in place. Okay, so I have a few kind of thoughts on hospital consideration. So we are obviously increasingly seeing these folks in hospitals because they need a higher level of care. And there's a lot of challenging kind of things that happen in this space, but props to a lot of the teams in Philadelphia that have been really trying to evolve their practice to make hospital care more accessible to people. For instance, people need surgical debridement, and I'm spotlighting Dr. Lisa Ray, who's the director of the Temple Burn team. She's been really a phenomenal champion for these patients and has been piloting some very exciting interventions, including a dermal substitute called BTM, which I'll share more about on the next slide, but has seen some pretty beautiful turnarounds with folks after getting a BTM, including as they continue to use. And some of the great benefits that she forwards about BTM is that they are stable, even in the context of continued use, and she will put a BTM on anybody to help facilitate healing, regardless of where they are in their substance use. And she says something really powerful, which is that when people see healing of their wounds, it can really move their hearts and they start to see hope for themselves in other ways too. And it can really be a huge step forward kind of globally, not just for their wound healing. So again, hope, this is hope we all need to know is out there and be sharing widely. I'll also mention that I think sometimes the understanding of a traditional or the traditional surgical debridement is to take not only the dead tissue, but to carve into the underlying wound bed as well, which kind of converts this chronic wound into an acute wound and resets the healing cascade. In the case of a xylosine-associated wound in a person who's continuing to use and may not be able to tolerate a full hospital course, we really encourage optimizing autolytic debridement and then a light or tissue-sparing form of surgical debridement to get kind of the majority of the dead tissue out, but without kind of making it essentially bigger using that traditional approach. But a freshly debrided wound, even tissue-sparing debrided wound is way easier to work with in the community than those huge shields of eschar that I showed in a previous photo. I'm just sharing this with you because I want folks to know that there are surgical teams out there who want to be involved in this care and championing kind of new and better treatment for folks. And this QR code will take you to kind of an info sheet that Dr. Lisa Rae put together about the BTM in the case of, in the treatment of xylosine-associated wounds. I've talked to a few infectious disease docs at a couple institutions. They all say, do not culture chronic wounds. If you have an acute infection of a chronic wound, so you have like a pocket of purulence of pus, you can go ahead and culture that. And there are a few kind of textbook criteria for assessing infection in a chronic wound like nerds and stones. So you may end up deciding to culture. We're not often biopsying these wounds, although we probably should be trying to. May not inform care for the individual, but it certainly would help build our understanding of the pathophysiology more generally. But the big thing is here, we're not often culturing chronic these wounds because it doesn't end up being helpful. Unfortunately, especially among folks who are unhoused and dependent on the unregulated drug supply, we're seeing a kind of relatively high frequency of repeated and interrupted antibiotic courses. And the consequences are starting to rear their ugly head. So at Temple and Penn, there is evidence of increasing doxy-resistant Staph aureus, especially high among folks who have substance use disorder. There are some potential alternatives here and Jefferson is pursuing a very cool antibiogram specific to this population, which will hopefully be informative, but ultimately without addressing the underlying conditions, I think this pretty scary thing is not going away. If you are in a hospital and you're not using full agonist opioids to treat people's fentanyl withdrawal, I'll just say that I'm sorry for your patient. So Temple, Boston and Hopkins and other places, I think have been doing this for years. We're now doing it at Penn as well. There's adjacent evidence for using full agonist to help people dependent on fentanyl transition to and stabilize on MOUD as well. So to help manage people's withdrawal as they transition into a longer term stabilization. And from my observations in the hospital, it has absolutely changed the game in terms of people's ability to stay in care longer and to get the wound care or whatever kind of medical care they need while they're in the hospital. So I've included a few snippets of the literature on this slide and we have Penn's protocol for using full agonists to treat fentanyl withdrawal posted online for anyone to check out, it's at PennCamp.org. If you're in a hospital and someone is self-discharging, know that there are many, many good reasons why they may be. Not least of all is that many people have undergone involuntary detox while in the hospital over and over again. And we know that opioid withdrawal is like a physiological stress state, not to mention the kind of stigmatizing treatment that people are often subjected to. So when people experience an activation of their stress response system recurrently in the same setting or environment, they develop essentially a PTSD. So people, hospitals can be highly triggering environments for people even in the best, even receiving the best care. So if someone is leaving and you're worried about them, you're worried about the risks of them leaving, which there are many, it is important to try and pivot to a harm reduction approach to this discharge. And this is a checklist that I try to use at Penn and socialize at other places too. The message we wanna send is that we care more about their health and safety than whether they're gonna do what we want them to do in this moment. And when this is the message, they're more likely to pick up treatment where they left off, they'll come back when they're ready. So things like giving them their antibiotics to take with them, giving them, or at least a prescription for those antibiotics, making sure they have naloxone in hand when they leave the door, a supply kit with a couple of dressing changes. These are really impactful, but really can't overstate how important it is to just tell people that their wounds can heal. So half of the battle with these wounds, and also we know in addiction generally is overcoming the internalized stigma and shame that people have. So you need to be told that recovery is possible and that you deserve it. So these are important moments to kind of make that plug and provide this encouragement. It's just really, really vital. I'm gonna skip this slide because it's basically saying what I've already said, but even if people leave before we want them to, if they have a positive experience, overall positive experience, that's gonna put them on this better trajectory, this better path towards improved quality of life and perhaps even recovery. So kind of centering that in our hospital care, in all of our care. And in the last couple of minutes here, I'll talk about some more kind of like harm reduction considerations. And most of this I've already touched on, but reemphasizing that because I'm reemphasizing these because they're the conversations that we have most often with folks in the prevention point clinic. So I think they're important. And a lot of this is getting comfortable talking to people about what we, and they already know is happening, but are sometimes hard conversations to have. So getting comfortable listening and validating while trying to offer information so that people can make the best decision for themselves. So picking at these wounds is very normal, especially for people who are using substances. It's something that you can kind of easily make a joke about, because it's normal for a lot of people to kind of pick at things, but the general rule is less is best. And adding or encouraging some kind of protection like gloves or hand sanitizer before touching a wound is really important. I've mentioned that the drainage is incredibly distressing. It gets on clothes, people are bullied and made fun of because of the odor. So we get why people dry their wounds out to manage this, but that wound won't heal while it's dried up. So what we really wanna offer this person is ways to address their concerns while supporting an optimal healing environment and building a dressing that does those things. Odor and insects are normal and even expected, especially for folks who are spending a lot of time outside, but again, incredibly distressing. So it is important to validate people's sensitivities around these things. I get, this is your body and I'm so sorry that you're feeling this way. Let's think of ways that we can address this. And just as with the drainage, often a very effective kind of, as simple as it can be intervention, it's just more frequent dressing changes, at least of that secondary dressing. So, but that means getting people access to supplies and encouraging kind of frequent care. So I see people who inject into their wounds, I'm sure that we all have. And I think this elicits a kind of knee-jerk reaction in a lot of this, but there are reasons and very understandable reasons for this. So you get decent drug absorbency in granulation tissue. So if you've had, if you've burned through your vasculature, which people do faster now than ever before, since fentanyl became the predominant opioid in the illicit drug supply, they might only have groin, neck and wound access. And to them, using a wound seems like a safer access than neck or groin. And it's a little bit hard to argue with that. People also fear that if they start using in a different location, they're gonna develop a new wound, another wound in that area. So another kind of decision made with risk reduction in mind. So having a real discussion with someone about why they're doing what they're doing, about options, learn from them what they feel their options are, and kind of understanding and talking through the pros and cons. Having this meaningful conversation about risk reduction is really important. I've heard a number of clinicians say to people, if you leave now or if you don't do this, you're gonna lose your arm. And I know, believe me, how scary and sad and many other things that it feels to see someone with one of these really progressed wounds. But this kind of like scare tactic only serves to validate the fear and the shame and the guilt that people already feel. And again, these are huge barriers to recovery of any kind. So instead, really lean into giving people hope. These wounds can heal. It takes time. There will be ups and downs, but you just keep coming back so that we can celebrate every inch of progress along the way. And from a psychosocial standpoint, this is an approach that keeps people engaged in care. We know that. I think I'm getting close to the end here. I'll just kind of drop here. My opinion is that people who use drugs and particularly people with fentanyl dependence who inject drugs are really excluded from a lot of care, from a lot of traditional care settings because we don't accept the realities of their condition and their needs. But that can change. So we can really re-envision how we deliver care and how we make care available to people. So Philadelphia has a number of low barrier wound care sites, similar to our Prevention Point Clinic, even lower barrier in some situations. And I think that can be a great model to replicate in other areas as this kind of harm spreads. And then the story of these wounds, as I kind of started out saying, is really a story of our unregulated drug supply. So whether you believe xylosine is the causative agent or not, there's really no contesting that these wounds are but one of many harms that come from a volatile and dangerous supply. Before there was xylosine, it was fentanyl. We all kind of wish for the days when it was just heroin before fentanyl. It continues to kill over 100,000 people a year and cause so much damage beyond that. So I do believe strongly that every one of these deaths is a drug policy failure. All of this harm is a drug policy failure. And so thinking about what safe supply can look like and advocating for that, I think is really important as well, an important part of this to keep in the discourse. If you'd like to read more, the Philadelphia City Health Department released a set of comprehensive recommendations for caring for folks with xylosine-associated wounds. This is the first of its kind in the country, I believe. I mean, you can check it out right from their website, SubstanceUsePhilly.com, or I'm happy to share it. And they also have a nice webinar that they used or they recorded upon releasing this guidance. Okay, so that's all that I have. I'm gonna stop sharing my screen. And I believe if we have some time, happy to take some questions. Yes, we have a lot of questions and comments so far. Thank you so much. We've gotten lots of people saying thank you for the talk, excellent talk, et cetera. I will start at the top here. Somebody had asked if the wounds can progress to a septic condition. Yes, so I would say, you know, people, a wound can become infected and a person can then become septic from that infection if it is not treated, you know, in a timely fashion. So we do see that in the hospital, people come in and they're febrile and they have a white count and they need admission for source control. We have another question. How would you differentiate this from Vetiform purpura? I'm going to defer that to a dermatologist, I think, or a infectious disease doc. Somebody about the wound care itself. Do you wipe the wound with gauze after the cleaning? So if tolerated during that first phase of cleansing with saline or water, if tolerated, yes, that's ideal because you can remove kind of the larger particulate debris. With a secondary cleansing, you can either saturate some gauze and lay that across the wound with your VOSH or antisept, and then when you pull it away, you get maybe a little bit of kind of mechanical debridement, but it's not necessary. If someone really can't tolerate, as many people cannot, a wiping of their wound, just letting the secondary cleanser kind of dwell in the wound is going to allow it to do its job. Do you find that highly potent opioids are needed for pain control, such as hydromorphone? I'm going to assume this question is about hospital care, and in that case, yes. So Penn's guidance for treating fentanyl withdrawal in the hospital makes use of a long and a short-acting opioid. So we most often use methadone and oxycodone immediate release, but we can also use oxycodone extended release and dilaudid. We can start people on dilaudid PCAs. Any of these kind of combination of short and fast-acting things to help stabilize withdrawal by mimicking how fentanyl's effect on the body and people's kind of need for it or withdrawal kind of syndrome from it. Somebody had asked, can you explain more about what xylosine does in a non-injection mode of use to have wounds that you show, even though people who use drugs, the person who uses drugs doesn't inject to avoid infection? Yeah, I mean, I can say as much as we know, which is not a lot, but xylosine does have systemic effects. So it does cause vasoconstriction and these transient hypotension in bradycardia and vasculopathy, which are going to be felt the most kind of on the periphery of our vascular system. So in the soft tissue, and that's kind of as far as we know. And then there's a little bit of a gap, but on the other side of that, we see people develop these, you know, ulcerations of necrotic tissue kind of scattered across their body. And we did not see that, at least in Prevention Points Wound Care Clinic before xylosine became a thing. So it seems that it is possible that these systemic effects from chronic xylosine exposure can then lead to small areas of compromised tissue. And maybe, as I mentioned, the initial insult was something else, maybe even something hard to discern, but it was enough of an insult within the context of recurrent xylosine exposure to turn into a necrotic wound. Thank you. Well, we're coming up, it's six o'clock now. So I want to be respectful of everybody's time and your time. I'd like to thank you so much for this awesome talk. We've gotten so much good feedback so far. So our slides are going to be posted online. And so you'll be able to access those in the education site on the AOM website, so where you signed up for this. Also, you'll need to complete your surveys too to get your CME credit. And our next webinar is going to be next week at five o'clock with Dr. Felipe Castillo, who's going to be discussing clinical implications of the relationship between naltrexone plasma levels and the subjective effects of heroin in humans. So I'd like to thank you again, Rachel, for the opportunity to learn from you about your experience providing wound care to people who are using fentanyl with xylosine. Thank you so much. Thank you.

xylosine-associated wounds

harm reduction

wound care management

infection prevention

moisture balance

debridement

pain management

sepsis prevention

collaborative care

safe supply initiatives