Prevalence of Wounds and Association With Xylazine Using Respondent-driven Sampling Among People Who Inject Drugs in Baltimore, Maryland

Objectives: To estimate the population-level prevalence of wounds and their association with xylazine use and other correlates, characterize wound features, and describe wound care experiences. Methods: Cross-sectional study in Baltimore, Maryland, between April and July 2024. Participants at least 18 years old, who resided in the Baltimore metropolitan area, and self-reported injecting drugs in the past year were recruited using respondent-driven sampling (RDS). Wound outcomes were self-reported history of any wound and xylazine-attributed wounds. Population proportions were generated using the RDS-II estimator. Robust Poisson regression with sampling weights was used to assess correlates of any wound history. Results: Among 315 participants, 39.4% had any wound history, of which 80.1% attributed at least 1 wound to xylazine. Homelessness, unemployment, and past 3-month nonmedical use of fentanyl, benzodiazepine, methamphetamine, and xylazine with other drugs were associated with higher wound prevalence. Those who experienced xylazine-attributed wounds (n=89) reported a small blister or bump (59.6%), necrotic eschar (52.8%), or necrotic slough (51.7%) and wounds at the injection site (61.8%). Health care-seeking behaviors were mixed, with participants reporting both seeking and avoiding or delaying care for xylazine-attributed wounds. Conclusions: These population-based estimates indicate a substantial burden of wounds among people who inject drugs in the Baltimore metropolitan area in 2024. More research is needed to strengthen the evidence base for xylazine-associated wounds to inform policy and clinical decision-making. Expanded training in wound progression and basic wound care will better prepare the health care and harm reduction workforce to manage wounds.