Wound-associated agents in the unregulated drug supply: Evidence from a statewide drug checking program

Background: While the unregulated drug market has seen dramatic increases in fentanyl adulteration in the past decade, other adulterants have impacted the recent volatility of the drug supply. There has been recent documentation related to the presence of wound-associated substances; however, there is a lack of data showing the prevalence of these substances across unregulated drug market samples over time. The aim of this paper is to examine known and potential wound-associated agents' (xylazine, levamisole, medetomidine) prevalence in Maryland's unregulated drug supply.

Methods: Using data from Maryland's statewide drug checking program, Rapid Analysis of Drugs (RAD), this paper discusses samples that were voluntarily provided at participating syringe service programs and analyzed at the National Institute of Standards and Technology between October 2021 and October 2023 (N= 2,210). We calculated prevalence and chi-square significance to assess co-occurrence of wound-associated agents and other substances and evaluated xylazine's prevalence over time.

Results: Xylazine was detected in 33.4 % of samples and primarily co-occurred with fentanyl; heroin and related compounds; and other opioids, stimulants, and anesthetics. Xylazine's prevalence decreased over time and varied geographically. Levamisole and medetomidine occurred in 1.9 % and 0.7 % of samples respectively with no significant co-occurrence.

Conclusion: These findings emphasize the importance of statewide monitoring amid an evolving drug market, especially regarding wound-associated agents. Drug checking, safer supply, overdose prevention, and non-stigmatizing wound care services for people who use drugs are instrumental in mitigating the health consequences of the unregulated drug supply.