Well, thanks for having me. I know folks have been in several other parts of this training leading up to the grand finale of Module 4. My name is Mike Chappell. I am an assistant professor at Columbia University. I'm one of the developers of this curriculum. We're working with many of the former trainers, Fernando, Jason, and others that have subbed in on these modules, and the idea behind Module 4 is to really pull together some of the information from prior modules, things that you learned, especially around wound care, and to think about whether you be a single organization or whether you represent multiple organizations in different disciplines. What are some of the things you can think about implementation-wise around wound care? I think we've worked with a lot of organizations over the last year or so doing this, and everybody comes to the table with different expectations and different goals and objectives, and the idea is to really think about how we can apply this in the work that we do. What's realistic? What's not realistic? Given our disciplines, I'm aware that there's a lot of folks on this call that are nurses, DMTs, medical professionals. Many of the individuals that we have worked with before have not been. We've worked with a lot of harm reduction organizations, treatment organizations, and others that are working with people who use drugs who are coming across these wounds caused by xylosine, looking to have some tools to respond in the field, but similarly, we've come across a lot of medical professionals that are looking for the same thing, and what we've learned is that medical professional or not, not everybody's trained in wound care, and so this really has intended to be basic first aid, and certainly your input is welcome, but the idea, again, is to really think about implementation. What are we doing on a daily basis? Where do we have room for this? What's realistic? What's not? What are some of the reset sources out there that could help us in this endeavor? And really kind of talk through that in a local context. So I'm going to kind of move along here, give you a little bit of an overview in terms of what this module is specifically about. Really, excuse me, really what we're talking about here is there's a couple of things, and I think overall they relate in one common way. When we think about expanding services, expanding implementation of services, we think about all the new challenges that come in our work every day, and the new things that we're being asked to learn, and then the new things we're being asked to do. We as practitioners, professionals, programs, organizations, whatever the case may be, we have to decide what's the fit for us, and really what makes things so intimidating a lot of times is that we don't have the knowledge, skills, or tools to be able to effectively deal with something. We seek out trainings like this to build those knowledge and skills, but we also have to think practically given our skill set and all the resources that we have available to us, what exactly is it that we're able to do, and we think about that in two ways. We think about that internally as an organization, how can we enhance our internal capacity to deliver wound care, and by internal I mean within the confines of the work that we do on behalf of our organization, which requires support from the organization, resources from the organization's policies and procedures, so on and so forth to support that work, and internal capacity is a really important thing because from a, from a strategic standpoint, the more that we can do internally, the more that we can do directly with our clients, our patients, the people that we're working with, the better it is for our clients. When we have to, when we have limitations and we have to refer people elsewhere or out for services, it's not as likely that they're going to get those services. Folks are, are, have trouble navigating the system. There's a lot of stigma involved. There's lack of motivation sometimes. Whatever the case may be, the more steps that we introduce to the process, the harder the process becomes for that individual, and so the more we can do internally, the more we can integrate within the confines of the work that we do, the better it is for our clients. We would like to be able to do a lot of things for our clients. We would like to be able to, to respond in a number of ways and not have to refer them out, so the, the balance is often thinking about, okay, how much can we do internally? What's realistic given what we do for a living, the setting in which we work, the resources that we have available in that setting, and how much, and, and what is a realistic sort of line that we can draw on the sand in terms of building internal capacity to do wound care? And then wherever that line is drawn, that's going to leave out capacity to do certain things without question. There, there are very few organizations in any example, whatever it is that you may be looking to integrate, that can do everything. There are always limitations, there are always limitations around skills, there are always limitations around resources, and then otherwise. So whatever you can't incorporate, whatever you can't integrate, you have to think about what can you do to build external capacity to address this. So what that often means is thinking about what other organizations exist in the community and operate, what are they doing, what are their specialties, what are their, what are their resources, who do they serve, how do they serve them, and having a real strong awareness of what those resources are outside of our own walls, which is a lot harder to do, right? We all get so focused on our jobs and what we do in-house. We often don't know a lot of what's going on around us. I, you know, I'm guilty of that myself. And so it really is this balance between internal capacity and external capacity and figuring out how to maximize most so that we could deliver the most effective services to our clients. So that's a major theme of module four, really thinking through that puzzle, but also thinking about harm reduction strategies in general, whether they're delivered internally or externally, to mitigate some of the consequences, particularly in this case of xylosine, and that has to do with wounds, but that also has to do with other things. That has to do with its impact on overdose, that might have to do with its impact on overdose response and other things that you're encountering on a daily basis. And so as we go through this module, I'm definitely interested to hear from folks about any questions you may have. I don't mind to be interrupted. Anything, any examples you may have, it doesn't have to be a question. It could be an illustration of a point in the context of your work. I think that's always helpful. Again, we have different audiences every time and we have, you know, even if we have similar audiences, we have people living in different communities. You folks are in Vermont, we're in New York. We know Northeast has been a real hotbed for xylosine, particularly Philadelphia, in Pennsylvania, Maryland, New York, Connecticut, Vermont, New Hampshire, so on and so forth. This has really been the breeding ground in many ways. You've seen that information from Fernando's presentation in module one. The prevalence of this is increasing in the Midwest and slowly creeping up in the West, but in many ways we're sort of on the forefront of this. I think our experiences and what folks are seeing is helpful to us as we get information out there. One of the most interesting things about xylosine and the work that we're all doing and the course that we developed and the curriculum that we're trying to get out there is that we're just trying to do the best as we can do as information comes out. This is fairly new in some regards. You may also remember from Fernando's presentations that, you know, xylosine was first documented back in Puerto Rico around 2010, but we didn't hear a whole lot about it here, really didn't get here until much later, and we're still learning. In many ways, we like to say we're sort of building the plane as we fly. There's not a whole lot of scientific evidence out there regarding best practices. A lot of that is coming from the field, what we're seeing in the field, what we're gathering collaboratively and collectively, and so the idea is that we want to share that as well because we relay that information back to learners as we go through this process. When I talk about strategies to enhance internal capacity to provide effective wound care, I think we're talking about a few different related things. We're talking about routine screening and assessment. I'll talk about that in a minute. I mean it a little differently than I think it typically conveys. We're talking about, as a minimal intervention, wound care kits and the ability to get people resources and help them help themselves, but also we're talking about the provision of wound care. So we're talking about it on multiple levels, and again this is a reflection of what organizations or varying professionals think is most appropriate for them. So with routine screening and assessment for wound care, I mean the argument is fairly simple. As medical professionals, most of you would probably agree with the notion that early intervention saves lives, it saves money, it saves resources. Screening and assessment is about early identification. Early identification is about early intervention, right? The sooner we identify that something exists, that a problem exists, the sooner we can intervene before it escalates and before it becomes more dangerous and more costly, and so the idea is that wound care delivered, identified and delivered and responded to early can reduce morbidity and mortality and of course the associated health care costs, right? The long-term savings by early intervention have been well documented for so many different disease models and whatnot. I think that's a fairly common observation. The problem is oftentimes we're inclined not to get involved with something until it presents more severely and absolutely undeniably needs intervention, and so sometimes we don't want to put in the resources up front and in the long run end up costing more money, more time, more aggravation, more challenges. So really screening and assessment and the mindfulness around that is about early intervention, right? So when we talk about screening and assessment for wound care, we're really not talking about anything formal in our view. We're not talking about standardized wound care screens. They do exist. There are all kinds of inventories out there to assess wounds, to assess them more rigorously in terms of all different characteristics of a wound, size, shape, color, drainage, severity, infection and whatnot. You could really do a very detailed assessment on a wound. That's probably something for somebody who has that kind of a specialty, a wound care specialist, a physician, a nurse, somebody who's trained to actually do that. That's something that they're going to do in providing treatment. The idea of this course and the idea of intervention in this area is really focused more on basic first aid. So if you're thinking about a standardized wound care assessment, I would say it's really overkill for most people on the front line. You're coming up against something, you're responding to a call, you have a patient or a client in front of you. The idea is that we're not looking to formally assess anything, but we are looking to be conscious of this. We want this in our consciousness. We want to understand that when we're out there and we're doing our jobs, that this is an issue locally. Xylosine is prevalent in Vermont. I know that you guys have shared data. I know that there's a lot of data out there and a lot of the data that we get on xylosine prevalence comes from the medical examiner's office in terms of xylosine positive or xylosine involved overdoses. It comes from seizures of drugs. It comes from drug testing. It comes from a number of places. And we know that the prevalence is fairly strong. We also know that it's been increasing. So it's a risk. It's a potential risk. And if you're working, especially with a client who uses drugs, a person who uses drugs, and also if you know that they inject drugs where the risk is the greatest, then you know that that person's likely at risk. And if you have that information, you're in an advantageous position to sort of observe and inquire. The whole idea is to just keep it in your conscience, observe exposed areas of the skin, look for wounds. In module two, we talked a little bit about a lot of the hype and a lot of the concern and the chaos around xylosine has to do with the severe wounds that we're observing. But Jason also reviewed with you what early xylosine wounds look like. They look like purple blisters. The idea that you can observe exposed areas of the skin, and you can see if you see anything. And if you do, you can inquire with the individual about that. Hey, this is what's been going on lately. You may or may not have heard of this, but this is a particular risk in the supply right now. And this xylosine has been found in the supply. I can't speak to your specific supply, but I know that it's a risk. And one particularly concerning side effect of xylosine is the wounds that it's causing. So I'm wondering, I see something on your hand. Can I take a look at it? And do so. And if you don't see it, right, because we can't observe everything. Keep in mind that not only do people dress differently. We all live in the Northeast. It's going to get cold soon. People are going to be covered up more. But these wounds, no matter how minimal or severe they might be, they're stigmatizing as well. So people will work to cover them up. If folks have a wound, they may not be displaying it. If someone's wearing long sleeves in the middle of the summertime, I don't know if you guys have 95 degree heat today, but we did. So if somebody is wearing long sleeves and 95 degree heat, maybe they're covering something up. So you're also in more than probably eight out of 10 times, it's not going to be as easy as observing it. Ask, inquire, make it part of the conversation that you're having with folks, especially if you have indication that there's somebody who might be at risk. But otherwise, bring the idea of xylosine into your conversation. Ask questions. Hey, this is like I said, this is what's going on. There has been xylosine detected in the drug supply. Xylosine does cause some wounds. The wounds can be really tricky to treat if we don't intervene early. I'm wondering if you've noticed anything different. Have you developed any odd wounds on your skin? They can look like purple blisters. Anything you're not sure about, I'll take a look at, that sort of thing. Inquire. Typically, if you're knowledgeable about something and you're thoughtful about the way you inquire, clients will disclose. They want help, but they're also used to being stigmatized. So they don't tend to offer information out of fear of what the response may be. But if you show compassion and you show interest and you present and you offer them knowledge, they may very well be thrilled to tell you, yeah, actually I have been dealing with that. Can you take a look? I'd really appreciate some help. So you just have to be really kind of more proactive about it in terms of being really conscious about the risk and the threat and inquiring about that. And then follow up regularly with folks in the field. So that's just a little piece that I think we often forget. And it's really just a plug, again, to be super conscientious about it. A lot of times, it's like don't ask, don't tell. We have enough to do. We have enough to deal with. Unless someone brings a problem to me, I'm not going to seek it out. But to the extent that you can and especially where you believe it's appropriate, definitely inquire. It can make a big difference. So I think that's really the first line of defense is being, and hopefully you'll feel more comfortable about this if you feel like you have the skills to intervene. I think logically, folks, I mean, I would, I mean, I can speak for myself if I were sitting in a particular position and I knew this issue existed, but I didn't know what to do about it. I'm not going to be that inclined to ask about it. What's the use, right? Hey, any chance, you know, this is what's been going on. Do you have a xylosine wound? And they say, yeah, yeah, yeah, I've got this thing. You take a look at it and you look at it and you're like, well, that's, you know, I'm sorry, but I don't really know what to do about that. Right. Like who would put themselves in that position? So the idea is to back yourself, to equip yourself with the knowledge and the ammunition to address it so that hopefully you are more confident to inquire. And I think that that's, that's ultimately the sort of first step that you can take is bringing this into the conversation as much as is humanly possible. As you, as you do your work in the field and your programs and whatever else. So, I mean, I'll stop there for a second. I'm curious from folks, Stephanie, anyone else, what, what has that looked like? Has this, you know, is there a proactive approach to inquiring about this or are you having folks that are just kind of coming to you asking for help? Like, what does that really look like in your community? So I, I will invite other, so basically everyone on this call is likely from a different organization. We have a good variety of folks. I'm curious kind of what folks have seen. So I know there are some MRC people. I think there's some medical folks. Are people seeing a lot of it and how is it coming to your attention? Steph, can I jump in? Yeah, please. Can you hear me okay? So I'm not holding space just so I can hear Harvey going, who's going to talk first? Right. I think what I see, so I'm a nurse at a methadone clinic in Rutland. And I think what we see a lot of times with silencing wounds is that we either don't know about them and the patient don't feel comfortable talking about them until the point where they're becoming acute and they need to go to a higher level of care, aka go to the local emergency department, which I think for a lot of our patients has been a bad experience in the past just because of the stigma that they face. So one of the challenges that we kind of have encountered is just being able to kind of start that conversation earlier in the wound process with people. And I know what I've found is helpful is when I have new patients that are coming in to seek care at our clinic that are starting the induction process, is just make that part of the assessment. It's just asking casually if there's any wounds going on, if there's any spots, anything they're concerned about, any areas. And just starting that conversation much earlier. Sorry, my deputy helped me out today. So I found that is people are a lot more open to talking about that, to showing you what's going on with them, to kind of making that part of like an ongoing dialogue with the patients. You know, the next day, the following day when they come in to get their medication, I can follow up with them about that. And I found it's helpful to kind of start that conversation a little bit earlier as part of building a rapport with the patient rather than later on when they might be feeling a lot of shame about the wound, or they might not be willing to talk about it because they're worried what kind of medical treatment is going to be required at that point. Yeah. Thank you, John. I mean, that's a great example. You said you work at a methadone clinic, right? So, you know, you're dealing with a lot of patients who, people who use drugs as your population, many of them probably inject, many of them are at risk. And so, you know, having that conversation early is a pretty, a pretty good use of resources and time because there's a pretty good chance that many of your clients and your participants are affected by it. And I think there is a lot of shame around it. So they're not often going to volunteer. These are folks that have been stigmatized many, many, many times before, even though they're in treatment where that, you know, they feel like they should be in a safe space. And now these wounds are like these really, some of them are these really gnarly sort of physical indicators of drug use, right? And so it's not just the shame that may come around for a person who uses drugs, but now they've got this really bad wound on their arm or on their leg or something like that. And they're ashamed of it. You know, they're ashamed of it and they're not going to volunteer it oftentimes. And even like you said, sometimes they may not even say anything until it's really acute and they need to go to the hospital. We've seen many times where they won't even say anything then. They won't even say anything then because they know if they go to the hospital, they may experience what they've experienced before. So, and that really speaks volumes. If you've seen some of these wounds and you see what people are willing to ignore temporarily to avoid further stigma and embarrassing, that really speaks volumes about the experiences that they've had previously. So, it's absolutely critical. And that really illustrates well, the entire point of this segment, which is just like, bring it up. When you bring it up, that has more power than you realize. Someone could actually say, oh, like they're actually aware of this. They know about this. Maybe they can actually help me. That sort of thing. I think it's really, really powerful. And I think it really lends. And you could also think from a programmatic perspective, sometimes things that work well, obviously having that one-on-one conversation, integrating it into the assessment, like you suggested, making it part of the, some of the initial discussions, but also posting information around the clinic. Xylosine adulterated in the opioid supply. Here are some negative side effects. Get posters, get pamphlets, the information's out there. Just make it visible. Make it known to them that this is an issue you're aware of and that they can actually get support at your program. And I'm talking to you, John, but I'm talking to everybody. I think those things go a long way and it helps make people feel safe. Thank you for sharing. Does anybody else want to comment? We don't, nobody has to, but I don't want to talk at you for an hour and a half either. Rebecca, I saw that you had had your, you off of mute. I wasn't sure if that was for a question or not. Well, I was just going to say I'm a volunteer with MRC and I've only worked in one clinic where we saw, it was at the needle exchange location here in Burlington and everybody had terrible wounds. And they had, we did ask about them. Most of them were at some stage of healing. A couple people had been in the hospital. I'm assuming for that was part of what they were in for because they had some pretty, you know, they looked like they were getting better, but that was the first time for me. I mean, this is kind of new for me. So, first time seeing all of that and it's helpful to hear how to, because I'll be working there again next month, I guess, but just how to approach people about this because it's like, oh my God, these things are terrible looking, you know, and where do you go? I mean, where do you go from there and providing, you know, they know what their, they seem to know what their resources were, but get, you know, the next steps for, you know, I'm interested to hear that. So, that was really all I had to say about it. Yeah. We're going to talk through some of the next steps, I think, really around wound care kits, wound care, things like that. Absolutely. I think, yeah, I do think that, you know, we have an opportunity here. We have an opportunity to really be conscientious about this. I think we know, we know the risk, we know who's at risk, and we can get, we can find ways to get information out there in different ways and to be comfortable about it, to be comfortable. So, I can tell you that from the data that we gathered prior to developing this curriculum, we were just really trying to understand what the impact of this was, what was the prevalence, what was the severity of some of these wounds. We gathered a lot of data. Any one of the previous trainers may have talked about the pilot study that led to the development of this curriculum. Long story short, we contacted over 600 people doing outreach, 600 unique people. Many of them we saw multiple times over a five, six-month period. We actually did a formal wound care assessment. We only did that because we were collecting data, not because we were necessarily just looking to intervene, and then we did wound care. We handed out wound care kits, showed them how to do wound care, and did that sort of stuff. But I can tell you, we oftentimes are inclined to think nobody wants us butting into their business. Nobody wants to be asked these questions. We had no trouble whatsoever. We had no trouble whatsoever. We were brand new. We weren't people they were used to. We weren't part of the programs that they were getting outreach services from. We were a resource, and we had a way to approach them in a compassionate and considerate way. And people revealed a whole lot of information, talked to us about a whole lot of things, showed us wounds in every part of their body. I mean, we got a lot of information. So we can often, as human beings, and I'm a New Yorker, so my whole philosophy is like, nobody wants to hear from you. Don't butt into anybody's business. Keep walking. We often think that way here because there are so many of us. But the reality is that it's not the case. If you have the right approach, and you have something that they need and they want, they're going to be very relieved to know that not only do you care, but that you have, you know, that you have resources and you have options for them. So. I would just add to, especially for like EMS folks, you know, we all know that when we go to a call and it's, you know, difficulty breathing or a splinter or something, and if you make that connection and like you're kind to that person, they will then tell you every single doctor visit that they ever had for the last 10 years. And like, especially thinking of populations that are like marginalized, being human and like that empathy and being kind could be like, you might be the only person that's nice to them that day and can really offer up. Maybe it's not the call that you go to right now. Maybe it's the next time you see them. But it is thinking about the impact that you can make and just asking and being kind and being a human and treating them like a human can really help to reduce that stigma. And even if they aren't like, don't necessarily want to go to the hospital with you today, like they might the next call, they might be more willing to, if they know that people are going to treat them humanely. Absolutely. Absolutely. They've had such bad experiences. You could develop rapport with somebody in 20 seconds by being nice in literally 20 seconds. They can tell by your body language, they can tell by a lot of things. So it's important, but it is also a great way. I mean, building rapport is a great way to get the information that you'll need to be able to actually help them. So, so just again, the takeaway here is don't be afraid to have the conversation, be conscious about having the conversation and you'll be surprised that at how much benefit there is to it to, you know, obviously to your client as well. So I know there are a lot of different organizations here doing different things, so I'm not going to get too into this. This is more of an organizational level focus, but the idea is about the possibility of doing wound care and setting boundaries. We talked a little bit about internal capacity, and so sometimes internal capacity will differ if you have co-located medical services, if you are a medical provider yourself, but even medical providers don't necessarily know wound care, right? That's a big piece of it, right? I mean, we have definitely have EMTs on this call. Are EMTs trained specifically to do wound care or do they typically provide first aid? What is the sense of that? I would think EMTs would be better trained to provide wound care than certain physicians, but I'm definitely curious. I welcome other EMS providers on here. I think we're definitely trained in some of my, probably some of the more basics parts of it. I think a lot of it is from the lens of like a trauma, someone's bleeding and how do we stop the blood from falling out of the body. But I know there's other folks on, so I welcome you to chat around your experience with wound care. And we're definitely trained on like how to do some wound care for like if someone's intestines are falling out and how to get them to that hospital, but slightly beyond the scope of this conversation. Right, right. And you might not get often get calls for, you know, for a xylitolazine wound, for example, it may be just something you observe on a call dealing with some other presenting problem. But what we have learned, and I'm, you know, I didn't really fully talk about myself in the beginning because I know we're limited on time, but I'm not a medical professional. I'm not a clinical professional. My specialty is in criminal justice. I've worked a lot with people who use drugs because of the fact that I work in the criminal justice, criminal legal system. But I don't, two years ago when we started this project, I didn't know anything about wound care. This was a partnership with our work being experts and working with a population of people who use drugs and then partnering with Columbia School of Nursing who obviously have more of the medical case, medical responsibility. And one of the probably more shocking things that I've learned for me, just because of my orientation and my background and where I come from, this might not be shocking to others, but was that, you know, if you walk into a hospital with a wound, in this case, like let's say a xylitolazine wound, and you walk into the ER, they may not actually know what to do about it. You know, they might be able to provide certain basics, but they don't, they might need a consult. They might need a wound care specialist, a wound care nurse specialist who goes through, you know, 60 to 80 hours of specialized training and clinical time to be able to understand in and out what needs to be done with that wound. It's a specialty, like anything else, it's a specialty. So many of us don't have the training, whether we're medical professionals or not, to do that type of wound care on that level, to have that type of assessment that maybe the client needs. And so it's a scarce resource sometimes. But what this curriculum was about was providing first, it really is about providing basic first aid, which is something that medical professionals, nurses, EMS, anyone else, physicians, physicians assistants, medical assistants, the list goes on and on, as well as people in the community, myself, outreach workers, harm reduction organizations, treatment organizations can provide basic first aid, and this was really intended to be simplified. So these slides, and it doesn't fit as well here, but these slides are a little bit about the idea that sometimes when you have co-located medical services, you might have more capacity to do things internally. And I say you might, because, and I tell you, I've learned there's a lot of organizations, hospitals included, that have wanted this training just as much as the layman, if you will, just as much as anybody else, because they don't feel like they have the capacity to do it either. And so one of the things that we've been talking about have been wound care kits. When we think about intervention, and we think about next steps, and we think about, we just went through, we had this conversation, we identified that somebody may have a wound, whether it's an early wound, a more severe wound, it doesn't even really matter necessarily whether it's caused by xylosine. There's not a whole lot of science that you treat a xylosine wound any differently necessarily than you treat a wound caused by something else, diabetes, whatever the case may be. There may be some harm reduction or mitigation steps that might differ if you know someone's injecting drugs with xylosine in it, but the treatment of the wound specifically itself, it's not all that specialized. And the idea is that we can think about providing wound care kits as a first line of defense. And I'm sure they talked about this when you did module two. We've worked really hard over time. We've had a couple of wound care specialists working on us with that. Everybody has their own way of doing things. Everybody has their own products and approaches that they like to implement, whether it be things that they have access to or things that they just think have worked particularly well for them. We've really tried to simplify it. We've really tried to simplify it to say like, this is basic first aid. While it might be nice to have a wound care kit with 30 supplies in it and all these other things, we want to streamline this and simplify this as much as possible. And so thinking about putting together custom kits that address the basics, right? And if you went through a module two, you have the idea that, right, you have a simple four or five step process. You're going to clean the wound with soap and water, right? You're going to apply a medicinal layer, right, to moisten the wounds. You don't want the wound to be dry. You want to clean it out, then you want to apply that layer. It could be A and D ointment. It could be meta honey. It could be zero form. It could be other things, right? There's a list of different supplies that you could have. It really may depend on a number of things, oftentimes cost, accessibility, et cetera, right? Then you want to cover it with something. If it's particularly moist, it might be like an ABD pad that is more absorbent, but it could just be gauze pad or something like that. And then you want to wrap it and then you want to secure the wrap. I mean, that's what wound care is. We've really tried to simplify it. I hope that's the message that you walked away with. And you can create wound care kits that have four, five, six supplies in them so that they're not that costly, right? And it's not that complicated. When we first started this, I mean, in full disclosure, we were having gallon Ziploc bags with band-aids and saline bullets and all these other things, which is fine. It's great to have supplies. People will use them. But then when it comes time to do wound care, you're like, all right, what do I use for what? I can't remember what's what, right? So we really tried to simplify it. Get it in a little sandwich bag, right? You've got soap and water. Maybe you have saline bullets. You're washing the wounds. Then you have something like A&D ointment to moisturize the wound that has some medicinal properties, right? Jason, who was the wound care nurse specialist, his thing was zero form. He treated so many of his patients out on the street. It was zero form. You could use meta honey. They don't recommend you do it with homeless populations because it attracts bugs. But meta honey is also very effective. You have the cover on it, some kind of a pad, gauze, something to cover it, a wrap, and then something to secure the wrap, right? Tape, whatever the case may be. Coban sort of secures itself. But if you put it on too tight, it could cut off circulation to the wound, which you don't want. So there's little considerations like that, which are really easy to learn. But wound care is about that simple. And the idea of the kits in particular is to really think about the fact that you can have the kit, you can demonstrate with the individual how to do it using supplies from the kit. And then a lot of organizations are handing out kits to that individual so that they can do it themselves. Basically saying to them, every two or three days, you want to change that dressing. And remember, this is how you do it. You apply this, this, this, then this, and you're done, right? That's sort of the simple way that we're promoting. And the wound care kits are a very important line of defense because a lot of times, like I said, folks do not want to go get treatment. They do not want to be referred to a hospital. They do not want to go on their own for certain. And the idea is that at the very least, if we think about it from a harm reduction approach, they will talk to you. They will take your advice. I bet you 99 out of a hundred times they will. And if you show them how to do it, you do it for them, show them how to do it in the process, they will help themselves. They will be willing to help themselves if you equip them with the supplies and the knowledge. And so that's better than nothing. Even if it's ideal that they should go to a hospital, if you notice signs of infection, you can have that conversation with them, but it's better than nothing. It's better than them not getting any treatment for it. And so wound care kits are a critical line of defense and the ability to sort of supply that a lot of harm reduction organizations are doing exactly what I described. They're dressing the wound, showing the client how to dress in the room and having them leave with supplies and doing it themselves, seeing them every week because they see them anyway for other things, a needle exchange, supervised use, whatever the case may be. And so they have that form. They have that ability to follow up, say, how's it doing? I can change it for you, take a look, that sort of thing. Not meant to substitute for medical advice, but it's basic first aid, like if you cut your knee, skateboarding or something. So I can pause there as well. Have wound care kits caught on anywhere? Is this practical? Feasible? So I definitely want to hear what other folks are seeing at the local level. So there are some organizations that are doing wound care kits. One of the things that we're looking at is the ability to incorporate it into like our EMS leave behind kits. So that should be rolling out probably this fall. And there is also some of the opiate settlement funding around a pilot with UVM and some of like the kind of connections to the more advanced work around the wound care, like the third step that you're talking about. But I'm curious for some of the methadone clinics or other folks, were you all seeing or hearing in your communities? And you can just say hypothetically, if you aren't comfortable, feel like you're going to out somebody. I know that some of the SSPs have done some training with NASTAD, I think it was last year around some of the wound care stuff, because I know they're seeing a lot of it. So we recently at my clinic, again, this is John from Westridge, and we have in the past year, we've gotten a lot of supplies from the hospital, but we haven't kind of gotten our act together in terms of implementing a plan we had originally kind of talked about putting together wound cares. And I think one of the most helpful things from this training so far is how you've presented the information, it's so straightforward and so easy to do, it's given me a lot of great ideas about how to put this in place. And I think that is really helpful for people, a lot of the strategies that you've presented as part of the series have been fantastic for me in terms of kind of thinking how I can make this happen where I work, and how this can help people. I think one of the really helpful things that you guys are discussing is just the idea of making this accessible and easy for people to take on themselves, right, if people don't want to access medical care, giving them the tools and the education so that they can take care of this themselves, and making it very manageable and empowering for the patients to kind of deal with this, to deal with their wounds themselves and not feel like they have to, you know, go to the hospital or, I also think it's important too to kind of, you know, for us is, you know, understanding what we can provide at our clinic versus when our patients need a higher level of care too. So nine times out of 10, because this hasn't been addressed, now the patients are stuck in a position where they have to go to emergency department or something like that, whereas, you know, if we kind of treat this, you know, if we kind of hit the ground running from day one, we can cut things off before they ever reach that point and help the patients feel like they've got it managed, they've got their health care managed on their own terms. Yeah. Yeah. Thank you, John. I mean, I think one of the things I hope folks walk away with, whether, John, in your situation or others, you know, if you're thinking about wound care kits and streamlining, and it can be, the reason why we're trying to simplify things so much is because people can get paralyzed by the amount of information that there is out there and not really know how to activate it. We really are thinking at a process that simple, four or five supplies, and maybe a card included in the, you know, in the little Ziploc bag with instructions on what to do, right? And you know, we can certainly give recommendations to any of the organizations through the opioid response network about what those, what those wound care kits could look like in terms of options that are maybe budget conscious or whatever the case may be. It, you know, there are definitely options. We don't endorse any particular, whether it be type of ointment or product of ointment or whatever the case may be. We just want to say like, okay, you've got, you've got, you know, four or five steps, four or five layers, and you're done like, and here are the options. And if you want something according to your budget, like there's something called VOSH, which is wound wash. It's very effective, but it's very expensive for a bottle, right? So there's a lot of other things you can use like soap and water that are just as effective. And Jason will tell you many times he's been out in the field and used Dawn dish soap because that's all he's had, right? So, so there's nothing hard and fast about this. The idea is that you can put these kits together yourself to be budget conscious, to be sort of accessible to your clients, to be accessible to staff in terms of being like, oh yeah, I could do this. This is all I got to do. I've got to take these four steps and I'm done like no problem. And I'll hand out a couple of kits and we're good to go. Like it really is that easy. So we're happy to advise on that. I think organizations should be thinking about it. You could be, you know, you can certainly be judicious in how you hand them out. You don't have to just hand out, you know, wound care kits to anyone and say, hey, if anyone needs these in the street, if that's what you want to do because you have the resources, great. But you could be more judicious about it as well, using it where you need to use it rather than being loose with the product. But it's also to say that like you don't have to go out and buy prepackaged wound care kits that have a lot of stuff you don't need and are more expensive. You can put them together yourself. You can do them in Ziploc bags. They don't need to they don't need to put in bags that have swag on them or anything like that. Like you could be very, very cost conscious and very simplistic with this and the ability for clients to do this on their own. They will absolutely do this on their own. I mean, at least as a starting point, at least as a way to get initial engagement. You have much better success with this than making a referral to treatment. And the earlier you do it, the less complications that are going to arise. But even so, I mean, I think Jason probably told you maybe the point didn't land without the benefit of this conversation. But even wounds that look pretty severe are actually very treatable through this basic first aid process. He will tell you that there are not many times in his career in the hundreds and hundreds of people that he's treated wounds where they actually needed to be hospitalized and given antibiotics and have intervention on that level. These are very treatable and this can go a long way. And so the ability to integrate wound care kits at the very least, I think, is a great step that different organizations that are doing different things can integrate within the work that they do. Does anybody else have any questions about this or comments that they want to share? And we can come back to this if anybody thinks of anything. I did put a comment in the chat just so there was in EMS, if you get HANS first, I apologize because I know we send a lot of them. But also I know that in 2023, there was an increase and we sent us a Health Alert Network back in February around increases in invasive group A strep infections in Vermont. So just adding that as a comment. Yeah, let me know if anything's in chat because when I'm in presenter mode, I can't even find where chat is. Thank you. So thinking about financing wound care interventions. When we started this project, and this may be something that some of you have a comment on, maybe that could be why there's not a lot of movement if there isn't, we knew that wound care kits were going to be important. They were an important part of the intervention that we were doing. We were trying to gather information on what was going out there. What was the prevalence? What was the severity? What did these wounds look like? How were they impacting clients? So on and so forth. And of course, gathering information, you never feel comfortable just doing that. We wanted to help these individuals. You're struggling with something. Here's a possible intervention. We have these kits. We're going to show you how to use them and and we're going to dress the wounds. And if you want to have a conversation or we feel like you may need to actually go get proper medical consult, we will have that conversation with you. But at the least, please consider using these wound care kits. And we felt good about that. Right. We felt like it was something it was a lot better than nothing. And they were really responsive to that. They did not want to go to the hospital almost to a T. There was very few were willing to go to the hospital, even with an escort. But they did want it. They did want to wound care kits and they did take them. And so that was a very good thing. Right. We saw how responsive they were to this. When we thought about expanding this process and doing this curriculum and thinking about how to train others to do it, one of our biggest concerns was like, oh, well, these wound care kits are great. But will organizations and programs and others be able to afford that? Right. Will they have room in their budget? That's something for everybody to think about. If we want to get these supplies, how do we get these supplies? Now, what I that was a concern going in. Right. Anytime you have an intervention that you think may not be sustainable because of the cost associated with it. A lot of times when we do things in research, it's funded by the it's funded by the research. Right. You pull that out. You ask communities to do it. They got to find the funds to be able to do the intervention. And, you know, wound care kits don't cost a fortune. Right. We're not talking about you know, we're not talking about X-ray scans or anything like that. But. We weren't sure, right, budgets are tight, there's everybody, there's there's needs for so many more things, there's a lot of competing interests. I can say probably that in a year of doing this and working with over 50 organizations, not one organization has said a word about money. Not one organization has said a word about money, and I'm having this conversation, right, I'm not I'm prompting the challenge. Right. And not one organization has had a struggle with that. They've seen the value in it. It's fairly inexpensive. They've gone about it in different ways. Most of them just kind of have the supplies. John, I think you mentioned you get supplies from a local hospital. That's a common approach. You could get supplies from a number of places. You could get donations. You could call manufacturers that might be able to get you supplies. There's all kinds of different ways to do it, get additional grant funding. But most of them have been able to just sort of get cued and work it within their budget because it's not super, super expensive. Right, but I wanted to bring it up in case if that's an issue for folks and folks are looking for guidance on that, it's really something that you have to first consider internally and moving budget. But most of the time, people working in their organizations, if we have medical professionals here, you're probably working in an environment where these supplies are laying around. If not, you may be working with organizations who have these supplies. Most folks, most programs, most organizations have been able just to sort of get it from. From collaborators and people that know that aren't using all the supplies, it's been fairly simplistic, but I obviously want to acknowledge that there is the cost of this. But if there are any questions or concerns about that, you know, certainly let me know. But I think it's something that you'd have to look into for sure in terms of getting down to the nuts and bolts of, well, what do we want to do for a wound care kit and how much is it going to cost us to put together that wound care kit? And if we how many wound care kits do we think we're actually going to need based on what we're seeing in our program? How are we going to hand them out? Are we going to give two to every client? Are we going to show them how to do it? Are we going to ask them to come back in? All those factors matter. So you probably can't really assess cost until you get a little bit further down the line anyway. But if you work for an organization that has a really tight budget and you know it's going to be a problem, it's something that you could consider right now as well and maybe get some input on how you could plug some of those gaps. So I really talked about this already, providing wound care education, it's not just doing the wound care, it's showing the client how to do the wound care. Right, that's important and giving them the supplies to do it themselves. And if you have regular contact with them or even if it's irregular contact, but you know that it's not only a one time, it's likely not to be only a one time encounter. You will be able to you will be able to check in on with them. You'll be able to see the progress. We saw a lot of progress informally where we were out in the streets. We were handing out wound care kits. Folks were using the supplies that were coming back. And either we were inquiring, but most of the time they were like, hey, look at my wound. It's getting much better. Like they were surprised how, you know, something fairly simple, given how serious it may be, have been perceived to be and probably would have gotten if left alone. They were really excited about the progress that was being made. So you'll get to see some of that. But really, it's about providing the education, helping them know how to do it. That's not uncommon from a lot of other things that we do when we go home from a doctor and they show us how to do something. They show us how to take our blood pressure. They show us how to, you know, administer insulin, all these other things that we do at home that make things more efficient. And so we're just teaching them how to help themselves. That's a big part of this. And I always say provide written guidance. When you hand out these wound care kits, don't count on the fact that they're going to remember, even if it seems really simple. Right. Don't count on the fact that they're going to remember every step. Some people get intimidated by things like that. Some people are very, very specific. They're very, very literate. They're very literal. Right. I always like it to those of us who like go to cook something and we look at a recipe, some of us can look at a recipe and go, all right, I kind of generally understand what's in there, I'll throw it together. Others of us may open it up and go, they want to follow each step in each order with the exact amount. And if they can't do that, they don't feel comfortable doing it. And so provide written instructions. So that they're confident in doing it, otherwise they may not do it. And the written instructions could be should be and could be fairly simple. Any questions about any of that internally, really talking about screening and assessment? Wound care kits and then the provision of wound care, that's that's where I think the opportunities lie here for a lot of organizations. So in terms of external capacity, what we're talking about a lot here, remember when I talked in the beginning, the things that maybe you can't do, the things that maybe you're not going to be able to build internally, the skills that you don't have, the resources that you don't have, which result in needing to make a referral. A lot of external capacity is about making referrals. Referring clients to services that you can't provide, that you know that they need. And an important part of this is engagement so that they trust your referral. Building knowledge about the resources around you so that you trust your referral. Right. And then identifying the partners that fit those needs, establishing the procedures, they're going to facilitate those referrals and all that sort of thing. Right. A lot of times we simplify referrals by just saying, OK, well, we know there's a local hospital down the road. We're going to refer them to that hospital and that hospital is going to do what they do. And that's what we do for everything. Well, sometimes we need to be a little bit more intentional about it because those resources aren't what they seem to be. Or that local hospital does not is not particularly receptive to people who use drugs. So we need to be a little bit more intentional about it. Or that local hospital does not is not particularly receptive to people who use drugs or they don't have the skills. If you send somebody there for wound care, they're going to say, well, we don't really know what to do about this. That's just going to ensure that the client walks out the door and says, forget it. So it's really about being a little bit more intentional around referrals and building that that capacity. So. Engagement is the first piece you already should be along that lines, thinking about engagement from the very first moment that you start interacting with a patient, a client, a participant, whatever the case may be. Right. It's all about engagement. Engagement is going to help them disclose whether or not they have a wound. It's going to help them take your intervention. If you want to provide wound care, if you want to provide a kid, if you want them to do their own wound care, it is also going to help with a referral if you feel like you need to make one. So it's important to meet them where they are at, which means that, you know, from a harm reduction approach, we're the experts in a lot of things. You may be a medical professional. You may be able to look at a wound and go, I don't really like that. I'm not comfortable with that. I think it may be infected. There's pus. That's it's your arm is hot. Like there are definitely signs of infection. You know, I think that you need to go to the hospital. And if they say, well, I don't want to go to the hospital, you know, you get to the point where you're like, well, if you don't go to the hospital, you're going to have serious consequences with this. What do you want me to tell you? Like getting frustrated about the fact that they're not taking advice. The whole point is to meet them where they're at, work with them, engage them, talk to them, provide kits, provide them with wound care, make the suggestion that they maybe seek extra care, but at least consider doing this. Consider, you know, treating your wounds, conceptualizing success from a harm reduction perspective. We're talking about risk mitigation, right? Sometimes we sort of know what's best. We know what's optimal, but we can't always expect that people are going to take that advice. So we sort of dial it back a little bit. We dial it back a step, two steps, three steps, whatever we know. What are you willing to do? OK, whatever it is that they're willing to do, that is an opportunity and that's how we need to think. So engagement is important. But what's really critical or concrete here is the idea of a referral network and thinking about a list of trusted medical professionals for a wound care referral. For a wound care referral, if that needs to happen, if there's the sense that more than basic first aid needs to be rendered. Who in the community is doing this sort of stuff? This is a fairly it's a fairly scarce resource in most places. Wound care, expertise, wound care specialization. Have you guys run into that? What have you seen? What what resources do you have? Is that something you think that exists but hasn't really been organized or tapped into? What's what's the sense in in your respective communities? So, um, I know, which probably most people, if not anyone probably doesn't isn't aware of. With some of the opiate settlement, there is like an agreement that's kind of being piloted right now around some of the wound care like for some of the infectious disease for one of our facilities, but that is like just happened. And so it's probably it's kind of being piloted with, I think, a select group so I don't know if anyone. I imagine that no one is aware of it on this call and there's like a bunch of work that needs to happen for this. But that will will be a resource at some point. Correct. Yeah. Has anybody run into a situation where they've had a client or a patient who, who they felt needed a higher level of care around the wound and they just. What did you do or, or did you not know what to do or has that come up it doesn't actually come up as often as you might think a lot of this basic for a first day can go a fairly long way but there are certainly those circumstances where there's the feeling that more is needed as anybody come across a situation like that. I mean, if the answer is no, that's wonderful. And sometimes that may be the feeling, but when the resource doesn't exist, there's not much you can do about it. But again, in that situation, provide basic first aid. That is a start. And I think the idea is to think about here, is there not an answer to the question because the resource doesn't exist? Or is there not an answer to the question because we're not sure whether the resource exists? We either know it doesn't exist, or we're not sure that it exists. And so talking to folks in the community, a lot of communities we've been in, larger communities than some areas where you may be in, like in Boston or New York City, there's like one or two games in town in terms of somebody who has this wound care expertise that's getting all these referrals. And it's not sustainable, but at least it's somebody. The idea is to think about the fact that A, does it exist? If we don't know, have we really exhausted all our options in terms of confirming that it doesn't exist? And if it doesn't exist, do we have the ability to build that capacity somewhere, somehow? A lot of places are thinking about that. There are hospitals that are thinking about integrating wound care specialists, at least some time from a wound care specialist. How can we build that capacity in our community when we need it? Because there will be cases that require it. And when it happens, it's not going to be a good feeling knowing that there's not at least an evident resource when it's needed. So I think that's conversations to be thinking about in the community. Like, how can we exhaust our various partners in having this discussion? Does anybody know? Maybe that somebody not on this call does know where this resource exists. And I think that's something that's really important to explore. Where does that specialty lie in our system of care? Do we have it? And that's thinking about some of that intentionality around referrals. And when you do and you have a resource, really building out that referral process in terms of a memorandum of understanding that outlines a lot of what's going to happen. MOUs, when we think about them on the surface, they sound like an administrative nightmare. Nobody gets excited about doing an MOU. I don't get excited about recommending doing an MOU. It's not fun. I understand that. But the purpose of an MOU is that so many collaborations and partnerships and referral systems are established upon relationships. They're established upon the fact that somebody in organization X knows somebody in organization Y. They have a good working relationship. They have an informal process in place. And they go about doing it all time and time again. Somebody leaves, either person X or person Y leaves, and that whole process falls apart. So the point of an MOU is to sort of routinize a relationship between two organizations. And in the process, you're spelling things out. You're spelling out who's going to handle what, what's going to happen when a referral is made, whose responsibility is what, so on and so forth. It really spellings everything out so that as people come and go and as staff turnover occurs, procedures are maintained, policies are maintained, practices are maintained. So the MOU helps build that organizational collaboration in a more formal way that's sustainable and also having a procedure for warm handoff. When we make referrals, we don't want to just make referrals. We don't want to just say, well, Lincoln Hospital's two blocks up on 145th Street. Check it out, right? That, okay, where am I going? Am I just walking into the ER? What am I doing, right? Handing a slip, like when I go to my doctor and I get a referral and he hands me a slip in chicken scratch that just says, call this person. And I call the person and the person goes, who's referring you? And I tell them my doctor's name and they say, well, I didn't hear anything from your doctor. Oh, well, I have this piece of paper. Would you like me to take a picture of it and text it to you? It gets very frustrating, right? There's a lot of back and forth. We'll go back to your doctor and get a formal referral. This is what we need. Have them fax it to me. Okay, well, we haven't received the fax. So have them fax, like, I know that that's going to happen. I'm like, all right, forget it. I'm not doing this, right? So really thinking about not only those referral procedures but a warm handoff where we're very explicit with the client. This is who I'm referring you to. I'm going to call that person for you. We're going to have a quick conference call. You're going to hear what to expect. You're going to get all your questions asked. Maybe I'm going to have someone even escort you over there. Whatever the case may be, warming up that handoff a little bit so that somebody feels a lot more comfortable and a lot more confident that they're going to get served when they take that next step. So really thinking intentionally about the referral process. We have a bunch of tips to share with medical professors. I'm not going to go over that right now. It's really about preparing the client, right? Remembering that before the appointment, during the appointment, after the appointment, all the different ways that they can organize themselves to make sure that they advocate for themselves, right? That they're prepared and they're ready to advocate for themselves. They've had some really bad experiences and they're not going into it very confident or comfortable. And the idea is to kind of help prepare them for their visits and help them understand. This may be out of the scope of some of the field work you guys are doing. It may not be relevant, that's fine. But the information's in the slide, the tips are fairly straightforward. But I think it's something that we overlook a lot in terms of the potential we have to help prepare our clients to be their own advocate and to know what they're entitled to, what they should expect, what they shouldn't expect and so on and so forth. So to kind of wrap up, I know we have about 20 minutes left, a little less than 20 minutes. I wanna talk a little bit about harm reduction strategies to mitigate some of the consequences of xylosine, the presence of xylosine as an adulterant in the opioid supply and really thinking about how we organize and how we prepare ourselves to do this. So one of the most important things is that we understand what the threat is, is that we really understand in our communities locally, what is the threat? What is the prevalence? How serious is it? How often is it in the supply? How much is in the supply? We can get all different kinds of data. So really leveraging existing surveillance data to identify threats associated with the drug supply, what's the prevalence of xylosine? I know you guys sent over some local data. I know some of it was integrated previously. I've seen data on Vermont. The prevalence is pretty high, right? Comparatively for sure. I mean, I think Vermont might have some of the highest metrics in the even higher than Philadelphia in some regards per capita and whatnot. So I think it's pretty well established. Now, my guess is that like, whether it be county by county or different communities that you probably don't have data at that level to be able to discern necessarily how Burlington may differ from Rutland or whatever the case may be, but you don't always necessarily need such finite data. Of course, always is helpful, but really establishing that there's a prevalence and there's a threat and monitoring over time. Is it going up? Is it going down? We're at the point where in many of these communities, whether you're in Vermont, New York, Philadelphia, wherever, that on an annual basis, whatever the metric is, especially if it's medical examiner, xylosine involved overdoses, that metric is sort of consistently going up year to year. More and more overdose deaths are involving xylosine. Doesn't mean xylosine caused the overdose, but there's xylosine in the system of somebody who's had a fatal overdose. So that often comes from post-mortem toxicology testing. That's probably one of the original sources of data and continues to be one of the common sources of data. Have you guys noticed any monumental changes? Is there anything of note or you're just well aware that it's there and it's been around for a couple of years now? So I had pulled it up before and now I can't find it with all of my screens. So in 2023, it was a little over 30% of our opioid overdose fatalities had xylosine in their system. And Vermont, I'll find it again. Vermont actually has had xylosine testing in mortality data for longer than I think a lot of the nation had. So we kind of see it, but essentially, yes, it's been increasing. Yeah, I'd say 30% is pretty high. Yeah, the first time it popped up, in 2019, there was 5% of deaths and then it has just gone up. Right, right, and remember, that's one metric, right? That's xylosine involved, so xylosine present in a post-mortem toxicology testing. So it was in the system of someone who had a fatal overdose. Then there's other levels, which is the next bullet, thinking about testing of the drug supply, what's in the supply, and you can look at that on a number of levels, right? You can look at it at like what percentage of the supply test positive for xylosine, but also what's the distribution in the sample, right? How much xylosine is in these samples? I don't know if you guys have that information, but there's data coming out of Philadelphia and other places that are starting to suggest that many of these samples are predominantly xylosine. They're predominantly xylosine. They're much less fentanyl, actually, which has a protective factor for overdose, much less fentanyl, really hardly no heroin whatsoever in any of these samples, right? So the idea is that people want heroin, and this so-called dope or this tranq dope, which is what they're calling it, more and more is becoming predominantly composed of xylosine so that when you take these drugs, you're taking mostly xylosine. You're taking more xylosine than you're taking anything else. So it's not just that it's there, it's that you're taking it in higher concentrations. And I don't know if you have data like that in Vermont, but that's also something that's incredibly useful. There are a couple of places that are doing it. I don't know exactly where it is, but then also with some of the opioid settlement funding, that there'll be more drug checking. There was some RFPs that went out earlier this summer. So there should be more of the checking of supply. Great, because that's great. I mean, that's really important data that's emerging here too as well. So those are some critical, and sometimes you get information from seizures, from law enforcement seizures. That's possible as well, and there's other things, but one of the challenges of this, right? Like the point is that it's good to be aware of what the threat is, where it exists, the extent to which it exists. But the landscape of xylosine surveillance is very erratic across the country, state by state, within states, county to county, whatever the case may be, it's really spotty, right? It's generally not include, they're not all the medical examiner's offices are testing for it. It depends on where you are. It's probably less common Midwest, out West, that they're actually testing for it. So some of the data that suggests that it's not there could be partially an artifact of the fact that they're not testing for it, right? You gotta be looking for something to find it. So there's that, right? We don't, we don't all, you know, whether you're county by county, state by state, we don't all have access to the same data. And so that's a big, that's a big limitation. When you're thinking about drug testing clients and whatnot, it's generally not included in routine immune assay, toxicology screens, there are panels for it, but it, you know, you have to target those panels and not all, not a lot of them have it. It's also, if you, even if you had it in a panel, it's very difficult to detect as it's rapidly eliminated from the body and metabolizes really quickly. So, you know, a negative test for xylosine in that way isn't necessarily gonna be an indication that the person hadn't consumed xylosine. Certainly xylosine that could later impact them in terms of the development of wounds. And so there are limitations as useful as the data is, the infrastructure is not there. It's not at anywhere near there. So that's challenging. So a lot of folks are just working with what they have. They're working with anecdotes. They're working with what they see in the field. They're working with what they hear. And that's how we're working too, in large part. So there are some resources here around, you know, xylosine surveillance. Then there's the xylosine test strips. Those are particularly useful and more widely being used, especially for individuals who really wanna know what they're consuming. You can certainly track data from them. It's harder to do, to implement a program like that around them. But they're fairly new on the market, obviously, because xylosine is fairly new. Exactly the same concept as fentanyl test strips. When they came out, they were more expensive. The price has certainly come down now. There was a consideration or a concern that they might not be able to keep up with the demand for them, but that hasn't been a problem. And certainly they've been tested in terms of their accuracy because, of course, a lot of folks are like, well, can we count on their accuracy? They're new. Are they as accurate as fentanyl test strips? So on and so forth. And largely the tests that have been done on them suggest that they're very acceptable in terms of accuracy. There are other challenges around administration, but I'm gonna pause for a second. Stephanie, I see you have your hand up. I was gonna say, so Vermont first got xylosine test strips in October of last year. And since around then, I'll say that for lack of a better word, they are included in the harm reduction packs that folks get, and then also all the EMS we buy in kits. And if I can calculate quickly enough, I could probably actually share in a second how many we've given out. Several, at least a couple hundred thousand dollars in the last year of xylosine test strips. Great, great. So, I mean, that's in these leave behind kits. You talked about wound care materials being included. All the precedent is there for the conversations that we talked about earlier, like this is well on the radar. That's excellent. These test strips are really effective. I think people want them. People who use drugs want them. They wanna know. Will they always alter their behavior because of it? Not necessarily, but at least they, because they may not have options, but at least they know what they're at risk for. And they may wanna know. And people have different reasons for wanting to know and how it informs their behavior. But the test strips are an excellent resource. They're effective, they're accurate. They should be used to the extent that you can use them. And I'm really glad to hear that they're being distributed. Certainly something I think that most people have incorporated, but, you know, important to go over. I think, and I think you were talking about this a moment ago when you talked about some of the opioid settlement funds, but drug checking machines are sort of a new strat, you know, relatively new strategy around, you know, around harm reduction and around, you know, information distribution. And so, you know, this is a technology basically where you can have folks bring in their drugs, bring in their samples. They can, you know, put it in the machine and it does require a trained technician and they can get results in terms of what the sample is composed of. And it can detect whether or not there's any xylosine in it. There are limitations. There has to be a certain amount in it to be able to detect it. All different sort of things around the clinic, the technician being trained and whatever else and whatnot. But this technology has been really useful. In New York City, there's a pilot program that's being run by the Department of Health where they finance these machines. And then they place these machines in harm reduction organizations. And those organizations had hours throughout the week where collectively the five organizations basically covered Monday to Friday, nine to five-ish, where someone could go get their drugs tested if they wanted. And, you know, the machines are about $40,000 to $60,000 each so they're not cheap. But there's a lot of, you know, with opioid settlement funds and other things, I wouldn't be surprised seeing these machines make their way into your community. And they produce a lot of really good data in terms of what's in the sample. We talked before about knowing what's in the sample, not just for the client, but also for the community. So does anybody have, Stephanie, are you aware that this is part, I think you were sort of alluding to this, is this part of the possible plan or? Yeah, so one, EMS has given out about 12,000 xylosine test strips this year, looking at my things. But yeah, so with opiate settlement funding, there were drug checking, like requests for proposals that went out and I know that they, so there are guidelines on the state health department website for what people can do and I'll see if they're public. But yeah, there are already some in Vermont and there will be more coming up. Great, yeah, and this is a resource for communities to track and to get data, but it's also a resource for the clients, just like xylosine test strips. The idea is that folks who wanna be informed about what they're consuming need these kinds of resources. And don't make the mistake that they don't care what they're taking because many of them do. They just don't necessarily have choices. Sometimes they trust their dealers. Sometimes their dealers don't know what they're selling. It works on multiple levels. Being able to do something like this and to have this resource and to know where people can access it is information that you wanna give out. Hey, if you're concerned about xylosine, I know where you can go get your sample tested. We have test strips. We have options for you. It's disseminating that information and those options and those resources. And so this is not gonna help anybody here necessarily, but this is what the machine looks like. And as I said, there's a schedule in terms of the various harm reduction organizations where folks can go and actually walk in and get their drugs tested. And the thing about it is that, worth mentioning is that it doesn't destroy any of the supply, which is a real incentive for participants. It's not like they have to forfeit a percentage of their supply to get it tested. It doesn't require much. They get back what they put in. And so it's really, there's really, really no disincentive to do something like this. If they don't wanna know and they don't wanna get tested, then they don't wanna know. But if they wanna know and they're curious or they want that information, there's really no disincentive. So it's gonna be a great resource. Make sure when it does come to your community, you're aware of where the resource exists and that you're spreading that information. And also talk a little bit, I don't think this is maybe for this audience necessarily, but we talk about supply side surveillance, supply side harm reduction. The same way we work with our clients, drug suppliers, drug dealers, they may have similar interests too in being more informed about what they're involved with. It's not a popular opinion necessarily, but it's one that we've seen work in the field when you bother to work with that population. We've got about four minutes. So I don't wanna get too deep into, there's some basic harm reduction strategies that have to do with safer use, safer injection, stuff that you can hand out that come in pamphlets and resources that you can gather. I think probably the most relevant to the audience here might be overdose response. And I'm curious in the four minutes or so that we have, the sort of science, if you will, on the impact of xylosine on overdose is very uncertain right now. Folks aren't real sure the extent to which xylosine exacerbates the risk of overdose if at all, right? It's a depressant, right? Central nervous system depressant, much like opioids are. So the thought is, is that if you add another to the equation that it's gonna intensify the risk, they actually don't really know that for sure. I would not say that the science is there yet. There are certainly some protective factors unintended of xylosine on overdose risk. I sort of mentioned it before a little bit, one of which is that because samples are becoming more increasingly comprised of xylosine and in the process, less fentanyl. Fentanyl is much higher risk for overdose. It's much more potent in terms of a drug and it acts differently on the central nervous system. And so having less fentanyl in the supply has actually impacted in a positive way overdose rates because people are not overdosing because they're not consuming as much fentanyl as they were in places where xylosine has become a bigger part of the, a bigger piece of the pie. But when it comes to overdose response, it gets tricky. We have EMS here. I'm sure folks can attest to that, right? When we were just dealing with opioids and we were dealing with heroin or fentanyl or whatever, folks were fairly confident in the ability to administer Narcan, get a response fairly quickly if it was indeed opioids and then move on, right? With whatever aftercare and whatever not is needed. When xylosine is involved and both are involved, it can be really tricky, right? Narcan doesn't reverse the effects of xylosine. Xylosine can produce prolonged periods of sleep and unconsciousness. You could administer a couple of doses of Narcan and if xylosine has them, they're not gonna necessarily awaken if xylosine is what is causing the sedation. And so it can be very confusing. And so what we often talk about is the idea of monitoring breathing. That was always part of the overdose response. Narcan simplified that a little bit, but monitoring breathing, make sure that people are breathing properly. A lot of outreach teams are bringing pulse oximeters out there to check oxygen levels and making sure that folks are indeed breathing. If they're breathing normally and they're unconscious, it's probably not necessarily opioids. But I'm just curious, and I know we don't have a lot of time, is there any for the MS out there and other staff that are encountering overdose probably on a regular basis, any specific challenges or specific strategies that you've implemented? I really want to hear what people that are doing a little bit more response right now. Someone said no in the comments. A couple things I'll just say. So if you are an EMS and you get the lead behind kits, the new harm reduction trifold does have resources around connecting people to some of the SSPs that have more stuff around like safer use practices and then for as far as the overdose response, I can say in looking at EMS data, we have had cycles where there's like the perception that it's like needing multiple doses of like more doses for Narcan. And then when there's been some law enforcement-y things, it was taking less doses for people to be reversed. But it's definitely a challenge and thinking of with our new EMS protocols and compassionate overdose response, like trying to fix the hypoxia is going to be re-emphasized because helping people breathe and not putting someone into like wicked withdrawals helps everybody. Yeah. Yeah. And I think it's important to just consider, you know, we've heard stories out of Philadelphia where they're, you know, folks on the streets are, you know, concerned about the amount of Narcan being used when xylosine is indeed the culprit. Because if you administer too much Narcan, you can precipitate withdrawal, right? And trying to figure out what that, you know, opioid withdrawal. And so trying to figure out what that balance is, I think is critical, you know, being able to, you know, knowing that we don't have all the information when we encounter something that looks like an overdose, right? We have to read the signs and symptoms. And so thinking about if you administer a dose or two of Narcan and the person doesn't come to, we're checking their breathing. And if they're breathing okay, in all likelihood, you know, it may be something other than opioids that is causing the issue. And of course, rescue breathing is always a critical, right? A critical intervention in that case where it's needed. So I think for, you know, an audience of EMTs and whatnot, you know, that's certainly something I think would be very relevant to your work, making sure you stay up with what are some of the changing recommendations around overdose response in areas where xylosine is a contributing factor. So in recognition of the time, I know we're way over.

wound care

module 4

xylosine-related wounds

medical training

first aid

internal capacity

external resources

wound care kits

harm reduction

financing

distribution

drug-testing