especially us who are, got it? Yeah, okay. Okay. A lot of us that are practicing any kind of care and harm reduction and medicine on the East Coast is, can I even do this? What is the medico legal realm that we're in? And so I think I spoke with Jason a few days ago where he was talking about, I don't know if it was just nurses, but they were going to the like New York board of nursing and saying, hey, we need to have like standing orders for nurses that don't have to necessarily have any kind of doctor's orders to be able to provide this care. How, because it's like where we're at in Maryland at least is we just want people to offer basic wound care, have supplies and be able to provide that consistency and for the nurses, if it's nurses, to just be doing their normal like case management, navigating care for people. So when it comes to, can I do advanced wound care? Like the thing that would be the most advanced that would help in this situation is being able to de-breed in the field, like sharp de-breedment or being able to like order specific de-breeding agents like Santel and for the most part, thankfully, a lot can be done without much, right? A lot can be done with really basic supplies. So that is not to answer that question fully, but it's to say like, you can just as a nurse, you don't necessarily have to receive a doctor's orders if you're just using basic supplies that are over the counter and that you're not telling someone, hey, I'm gonna heal this wound out in the community without any involvement in a higher level of care. So just trying to like work with the networks that that person already exists in with whatever care they receive, maybe primary care, some kind of specialty, if not at all, like just continuing to engage with them and seeing what relationship you can build and where that wound is progressing, whether it's healing, whether it's not and getting them engaged in care and like just reassuring them that, hey, when wherever spits you back out or they get done caring for you, I'm gonna be here and I can follow those doctor's orders, right? Because they might have a plan of care written from the emergency room or whoever the wound care clinic. So really just trying to get people to not feel so intimidated and just instantly say, no, I can't do this because no one's given me orders for it specifically, but just using that very basic, almost like first aid medical care mentality. Yeah, yeah, thank you so much for sharing with me. Yeah, for sure. I'm so glad that we have you here. Fernando, yes, please take it away. Okay, sorry again for the technical glitch there, but yeah, no, it's great to be here. My name's Fernando Montero, I'm a medical anthropologist. For the past 16 years, I have been doing research with people who use drugs and people who sell drugs in Philadelphia, trying to understand transformations to drug supply chains in the United States and the public health implications of those transformations. I also wanna apologize because I'm coming down with something and my voice is a little hoarse right now, but hopefully we'll be able to push through. Before I start the presentation, I wanna give a shout out to the Opioid Response Network who are very kindly sponsoring this presentation. Any community organization is very welcome to request trainings such as the one that we're delivering today. And I just wanna acknowledge that. And so I normally begin this presentation by presenting a brief history of the street supply in the United States. I always insist that it's very important to understand the state of the drug supply and the ways in which people use drugs in their everyday lives before the emergence of fentanyl, before the emergence of xylosine in order to really understand how fentanyl emerged in the places where it emerged and the public health impact that it had. And the same with xylosine, you need to understand the state of the market, the way that people use drugs before xylosine in order to understand how xylosine entered the supply and the impact that it is having on people, right? So I go back to 1991 because that is a very important year in the history of heroin in the United States. 1991 is the year when the market in the United States got divided into two, two very distinct monopolies, one on the West Coast, West of the Mississippi River, one on the East Coast, East of the Mississippi River. We had two very different supplies of heroin in the United States. Are you raising your hand? Just in case you want to show slides, we're not seeing any slides. Oh, really? I'm not. I see your feedback is important. Oh my God, one second. Can you see them now? That's great. Yep, thank you. Great. Okay. So we had two very different supplies of heroin in the United States in 1991. On the East Coast, we had a powder form of heroin that was produced in Colombia. On the West Coast, we had a gooey, black, waxy, sometimes solid substance that was produced in Mexico that is known as black tar. And it turns out these substances are actually different chemical compositions. Even though they're both heroin, they have different chemical compositions and they have different material characteristics. One is a fine powder. One is a gooey, waxy, solid substance. And that has huge implications for public health because it determines how people consume them. So black tar, because it is solid and gooey, had to be heated in water prior to injection. Whereas the powder heroin that we had in the East Coast doesn't have to be heated. You can dissolve it very easily in water. In fact, in Philadelphia, I have never seen people use heat to prepare a heroin solution. The other thing is that if people needed to reuse syringes, and again, remember, this is the 90s when syringe service programs were even more scarce than they are now, people were reusing, having obligatorily to reuse syringes all the time. If they wanted to reuse one in the West Coast, because they were using this very gooey substance, they had to flush the syringe with water very thoroughly, or else the syringe would clog, right? Whereas in the East Coast, the powder heroin was a very generous substance. You didn't have to flush the needle. Again, you didn't have to use heat. And these differences had huge public health implications. Epidemiologists found that HIV and hepatitis C rates among people who inject drugs on the West Coast were much lower than HIV and hepatitis C rates on the East Coast, because people who use injected drugs on the West had to flush the syringe and had to use heat, right? Those two actions that were mandatory to consume black tar heroin on the West Coast were protecting folks from contracting hepatitis C or HIV. So I insist that it's very, very important to look at the material characteristics of the substances that we're trying to understand. You can't just say that somebody is doing heroin. That means nothing, right? Again, black tar heroin is very different from powder heroin. It involves a completely different landscape of risk, completely different patterns of consumption, right? And this is what we had. We had this duopoly in the U.S., a market that was split into two, regional, geographically. And it was very stable. I mean, it stayed in place. This division stayed in place for 22 years. For a criminalized, unregulated market, that stability is remarkable. Impressive, actually, right? But that was true until 2013. 2013 is really when fentanyl begins to emerge in the United States. It emerged initially in the East Coast. Often when people talk about fentanyl, people imagine this kind of generalized phenomenon that took over every opioid market in the North American subcontinent at the same time. That was not the case. The emergence of fentanyl was a very regionalized phenomenon, and it had everything to do with this preexisting split in the heroin market. Because fentanyl emerged as a powder, and you could only really easily mix it into an already powdered form of heroin. Whereas black tar was almost impossible to adulterate, to mix with powder fentanyl, right? And it took a very long time for fentanyl to finally emerge on the West Coast. And it didn't emerge in the same ways as it did in the East. In the East, fentanyl was mixed into the preexisting form of powder heroin, and it was sold as heroin for a very long time. That would have been impossible in the West Coast. So again, another reason to pay attention to these details of the material characteristics of the substances that we're studying to understand transformations. Silazine begins to emerge around 2017 in cities like Philadelphia, again in the East Coast, because silazine enters the supply as a powder. And again, it's easier to mix into the powdered forms of opioids that we have had in the East Coast since 1991. Actually, since longer than that. And by 2020, heroin had essentially disappeared. Drug checking programs find heroin sporadically here and there, but heroin is increasingly rare. On the East Coast, the opiate supply is essentially a mix of fentanyl and silazine. The West Coast is very interesting because it has changed into a predominantly smoking market. Many people are not injecting anymore. And in cities like Seattle, the opiate market is actually, the street opiate market is a pill-oriented market. What people buy there are pressed pills that contain fentanyl. They know that it's fentanyl, and they crush them, place the powder in foil, and then they inject it and place the powder in foil, light the foil, and then draw up the smoke using a pipe, a straight or a hollowed out big pen, this kind of thing. And it actually took a huge transformation of the West Coast market from black tar heroin market to a pill-oriented market for fentanyl to really finally take over the West Coast market. So again, a very, very different pattern, similar transformation, but it followed a very, very different pattern, right? And it was uneven historically. One interesting thing that has been happening in the East Coast alongside these changes is that methamphetamine has been emerging as an important substance. Back when I lived in Philadelphia between 2008 and 2012, I never ever saw methamphetamine on the street corners that were selling heroin, cocaine, and crack. Now about a third of the corners that sell heroin, cocaine, and crack are also selling methamphetamine. And methamphetamine has been, well, it rose in popularity around 2020, 2021. Now it's interestingly competing with cocaine and crack, but we can talk about that later. But so this slide really is just to spell out the fact that fentanyl spread was uneven, that its spread was conditioned by pre-existing geographic differences in the heroin formulations that were available in different parts of the country. And the second bullet point is a bit of an unsequitur, but it's something that I feel has not been emphasized enough in the literature on this and in research on this. Fentanyl enters a country already heavily diluted. It's such a potent respiratory depressant that even at the level of international wholesale, it's only circulating in a highly diluted form. When the DEA or the Customs and Border Protection confiscate fentanyl at the border, they're finding it at purity levels, at concentration levels, averaging 1.5 to 10%, which is also interesting because that's the concentration that we tend to find in Philadelphia as well. Generally dope bags here average between two and 10%. I'm running my own drug checking project in Philadelphia that I'm happy to talk to you about. I happen to be two blocks from Kensington Avenue right now. So another thing that I think is really important to understand about fentanyl that has to do with its relationship with the pre-existing forms of heroin that were present before fentanyl's emergence. And that's also very important to understand, Silas, is that fentanyl produces a very different type of high than heroin, right? This is very important for people who are dependent on opioids and use opioids every day. When we read descriptions of fentanyl, we often just read that fentanyl is more potent than heroin, right? And everybody seems to have a different number for how much more potent fentanyl is than heroin, right? But I insist that that's actually a very poor way of describing fentanyl and of understanding fentanyl. It is true that fentanyl binds more potently to new opioid receptors, right? And that results in greater respiratory depression. And this is why it's more likely for a person to overdose from fentanyl than from heroin, right? People die of an opioid overdose, they stop breathing and they die. You all know this better than me, right? This is very different from a stimulant overdose, which generally triggers a heart attack or a seizure or a stroke. Very, very different forms of overdose. So it is true that fentanyl is more potent than heroin in that sense. But in almost every other way that has to do with the experience of consuming opioids, fentanyl is worse than heroin, not better, right? We, when people think, when people hear that a substance is more potent than another, they assume that that new substance is offering a better experience or a better high because it's more potent. That is absolutely not the case. The most important way in which fentanyl is worse than heroin is that it has a shorter metabolic half-life, right? So its duration is much, much shorter than heroin's, right? And for people who use drugs, this is a huge problem, right? It means that they have to use more, they have to buy more, they inject, they have to inject more frequently, they have to share syringes more frequently, right? And this has always been recognized as a problem of the heroin era. This is one of the ways in which fentanyl is inferior to heroin. The other thing that has become somewhat more difficult to get descriptions of, has to do with the very quality of the fentanyl high compared to the heroin. This was easier to elucidate in the early stages of the fentanyl era. I remember the fentanyl emerged in 2013, right? Some people still talk about it like it's a new phenomenon. This phenomenon is over a decade old, right? And so many recent initiates to opiate consumption don't even know what a heroin high is, right? And can't compare it to a fentanyl high. Many people kind of lost track of where the transformation from heroin to fentanyl happened. And so they've also, it's become harder for them even to describe the difference between one high and the other. But in the very early stages of fentanyl's emergence, people were very clear in that fentanyl produced the worst high. And I remember very vivid descriptions of folks saying that fentanyl produced a much more localized high. Heroin was this kind of holistic full body embrace that people very much enjoyed. Fentanyl produced a much more localized effect that was concentrated in the neck and the face. Some people described it as a flushing feeling in the face, not as satisfying as the holistic full body embrace of heroin. And these ways that fentanyl is inferior to heroin are very important because they help to explain why new substances have emerged and why those new substances have some staying powers. It helps to understand the emergence of xylosine and it helps to understand the emergence of methamphetamine in the East Coast. We're gonna come back to this point in a second. So I'm sure by now you all know the ins and outs of the pharmacology of xylosine. Xylosine was originally, or for many decades used, continues to be used as a veterinary analgesic, sedative, and muscle relaxant. As a heroin adulterant, it was first detected in the 2000s in rural Puerto Rican drug markets. Very interestingly, I mean, I have a friend, Rafael Torroya in Puerto Rico who runs a syringe service program there, who took me to some of the mountain towns where xylosine was having a huge impact in the late 2000s. And it was very interesting because these were towns where horses were being bred for the race horse market in the mainland United States. As the xylosine was used very commonly in those places, partly for the treatment of those animals and also to facilitate their transportation to the mainland. You had to put horses in a cargo ship, right, to transport them from the island of Puerto Rico to the mainland United States. And xylosine was used as a tranquilizer to facilitate transportation. And it is those towns where xylosine first emerged in the heroin supply. And to this day, many of us are still citing really the initial Puerto Rican public health literature that documented xylosine submergence that began to document the impact of xylosine on public health and on the experience of people who use drugs, right? They were the first to identify these new types of wounds, skin wounds that were different from traditional heroin abscesses. They were the first to document the long periods of sedation of deep sleep that people fall into after consuming xylosine in high concentrations. And they were also the first to begin to advance hypotheses of why all these things were happening. I mean, they were going back to the Eastern European literature from the 70s and 80s on xylosine in rats that showed that xylosine was a basic constrictor that's causing skin wounds in rats. They were doing types of literature review that we actually don't see very often in the newer literature on xylosine. I began studying xylosine already somewhat late in the process of other people did it before me. Harm reductionists had been well-versed in its presence for four years before I began doing my own research on this. But right after the COVID moratorium in early 2021, I went back to Philly to visit my old neighbors and my old friends. And this is really the first time that I began to hear about Trank and the way that it was kind of making a huge impact on the opiate supply in Kensington and Philly. Because so many- On this topic, I was just talking with my colleague and in Saratoga County, upstate New York, we showed the most recent data shows 33% of our opioid overdoses is xylosine related. Quite, substantially higher than what I expected. That's fatal overdoses, not just overdoses. Thank you, thank you. Yes, please, thank you. Yeah, that gives you a good indication that xylosine is highly prevalent in your opiate supply, right? Yeah. Yeah, and so in early 2021, there had already been a couple of articles published by the Philadelphia Department of Public Health. But it wasn't widely known that xylosine was making an impact, right? And so my research team and I decided that we needed to get the word out as much as possible or contribute to getting the word out. And we began calling medical examiner's offices and coroner's offices across the country to see if they were testing for silencing, what kind of data they had. We were able to get data from 10 different jurisdictions. The data was very uneven. Sometimes it was a city that had data, sometimes it was a state, right? And so, you know, a quantitative specialist, a data analyst would look back at that article and say that it wasn't rigorous enough or whatever. But the thing is, you know, we just wanted to get as much data as possible to get the word out that this was happening, right? And the data from those 10 jurisdictions that were testing for silencing already in 2021 showed that silencing's implication in overdose mortality across the country had risen from 0.36% of deaths in 2015 to 6.7% in 2020, right? At that point in 2020, the highest silencing prevalence was observed in Philadelphia where 34.7% of deaths already involved silencing or had silencing present, right? We're gonna go back to the question of that potential causation or lack of causation between silencing and overdose. But that was a very interesting finding. And then the most important finding really at that time was that in Philadelphia in 2020, fentanyl was present in 98.4% of silencing involved overdose deaths. That already told us that fentanyl and silencing kind of go hand in hand, right? That you can't find silencing by itself. Nobody can go out to a corner to buy tranq, to buy silencing. That's just not a thing, right? Silencing is always mixed with fentanyl and what people are buying is what is known as dope. And the dope is a combination of tranq and fentanyl, right? Nobody again, nobody's going out to a corner to seek as silencing by itself. So Philadelphia actually has a very, very good drug checking program. It's also probably the most generous in publishing its data. And they have found very interesting findings. So among the samples that they test, the average dope sample consists of two to 10% fentanyl and 30 to 40% silencing and virtually no heroin, right? So it is important to note that silencing is the bulk of the substance that people are consuming when they use dope in Philadelphia and much of the Northeast. This data also is interesting in that it tells you that suppliers are regulating themselves in the context of criminalization and lack of regulation because they realize that fentanyl is a very potent respiratory depressant and they can't be selling bags that are 100% fentanyl or 50% fentanyl, you know, right? You find a bag every so often that will be, that will have a very high concentration of fentanyl. But for the most part, the data from Philadelphia, from this drug checking program is telling us that suppliers are actually keeping the fentanyl concentration at a low level. Presumably in knowledge that, you know, it doesn't help them to kill their customers or to attract police attention by causing a lot of overdose deaths. So Chris actually offered more recent statistics on New York State. I had added a few of the statistics I was able to find online, but this is already outdated data from 2021 when only 5.2% of opiate overdose deaths in New York State also involves ilazine, right? Chris just offered us data. Where were you able to find that data? In Saratoga County. That was one of the emails, that was New York State data. There's a Saratoga County opioid overdose dashboard where they do like live data posting from through ODMAP. So that's where that data came from. But the New York slash New York City data that we have that's most recent that what Chris is probably talking about is like 23%, right, Chris? I'll have to go back. That's great. I'm very glad that you have more recent data, right? It clearly shows that there has been an increase from 2021 to 2023 in the prevalence of xylazine. This is also somewhat outdated data, data from the DEA on xylazine positive overdose deaths by region. This data has to be taken with a huge grain of salt because many jurisdictions are still not testing for xylazine. Different jurisdictions have inconsistent protocols for testing and reporting. So these numbers are actually likely to be much higher in every region. But I still show this table because in terms of relative magnitude, in terms of showing us which regions are most impacted by the prevalence of xylazine, I think it is generally accurate. It shows us that the Northeast and the South of the United States are the regions with the highest prevalence. And it shows us that the West is actually taking a very long time to catch up. Xylazine's spread is following a similar, somewhat similar pattern as fentanyl spread, right? Remember that fentanyl, it took a long time for fentanyl to finally spread to the West given the ease with which you can mix fentanyl into powder heroin and yeast and the difficulties in mixing fentanyl into black tar heroin in the West. This data is somewhat more accurate. This is data from- Sir, question, sir, question. Yeah. Could I ask, what else is in xylazine? So I'm interested in seemingly inert ingredients and other things that end up as a result of manufacturing processes, those kinds of things. And so is xylazine all xylazine or are there other things present in it as well? And when you were talking about fentanyl being only two to 10% and xylazine being 30 to 40%, no heroin, what else is in that percentage? Do you have a sense of that by chance? Yeah, so this is the average dope bag in Philadelphia, right? This is a $5 bag, usually about 100 milligrams. And they found that the average dope bag is composed of two to 10% fentanyl, 30 to 40% xylazine, right? So that takes you up to about 50% of the substance. The other additives are usually like traditional bulking agents. They're pretty similar to what people were using before. Fentanyl, xylazine, mannitol, inositol, they're generally inactive ingredients that dissolve very easily in water, which is very important for people who need to easily dissolve a substance to inject it. You know, I now have my own drug checking program, so I'm seeing way more details that I kind of hadn't seen before. There are some things like lidocaine or tetracaine, like a local anesthetics that are being used as bulking agents that are semi-active and that they do have a kind of effect. And lidocaine will numb the site of the injection for a little bit, and some people might enjoy that. It might also provide pain relief for people who have open wounds. But generally not that many things of concern in addition to xylazine and fentanyl. Every now and then you'll have a fentanyl analog in a very low concentration, or even as a trace, you know, like fluorofentanyl. I haven't really seen, I have not seen carfentanil. I've already tested like 300 samples in the last three months haven't seen carfentanil once. Fluorofentanyl has come up. Generally, that's the story of Philadelphia. I can also tell you about the cocaine, which is another very interesting thing. We've been testing that as well, and breast pills. Yeah, go ahead, I mean, why not? The cocaine is interesting because it is very pure. It's very unadulterated for the most part. People are actually very impressed. People on the street here are very impressed with the quality of the local cocaine, especially the crack. The crack is purer than the cocaine. I mean, the crack is very difficult to adulterate because you need to cook it in order to turn it into, you know, a rock. And in that process, it's hard to put into many, additives, and it has to be sold as a rock. Nobody will sell to, will buy you crack powder. You know, people want to see the rock. So crack is generally unadulterated. In cocaine, we do see also lidocaine, tetracane, sometimes a little bit of methamphetamine. We still haven't tested a single cocaine sample containing fentanyl or xylosine. Yeah, sometimes you will see, this is one interesting finding. I don't want to go too far into this because then we'll run out of time. And I know that, you know, Lizzie's part of the workshop is probably the most important since it's about the actual wound care. But one thing that we've seen is the use of the most common cocaine metabolite, benzoglyc, Lizzie, do you know what the name of that is? Benzoglycine, which is very interesting because that's the substance that cocaine urine tests test for. It's basically when your body breaks down cocaine, this is the first substance that emerges in the body, right? Benzoglycine or something like that. And it's very interesting that some of our cocaine samples have that as the primary component. It's almost like a bulking agent that will not ever get detected in a urine test. And that's not very active. It doesn't have the effect of cocaine. It's an actual metabolite. People find it in powder and mix it into cocaine, but it's not known to be harmful. That's the one interesting finding in our cocaine samples. So this is the data in this graph is from Millennium Health. This is a lab that tests urine samples submitted by doctors for many different reasons across the country. And their data generally confirms what harm reductionists are seeing ethnographically. That psilocybin positivity is most common in our region, basically the mid-Atlantic and the East North Central region, South Atlantic. So yeah, Benzoglycine, thank you, Lizzie. I don't even know how to pronounce that. So I wanted to share with you some of the statements that I heard from people who use drugs in Philadelphia back in 2021, that there's a lot of people who use drugs in Philadelphia. And there's a lot of people who use drugs in Philadelphia and they don't even know how to pronounce it. So I wanted to share with you some of the statements that I heard from people who use drugs in Philadelphia in 2021 that allowed me to understand what xylosine is doing to the experience of opioid consumption and also helped me understand reasons for xylosine staying power. I do want to clarify before I go into this that xylosine's introduction is mostly a supply-driven phenomenon. The most important reason why xylosine is being introduced into the supply is because it is cheaper at the wholesale level than fentanyl. I have been doing research among people who sell drugs here for a very long time and they have explained that a single vial of xylosine locally at Philadelphia is $150. And if you put that vial, empty it into a microwave dish, put it in the microwave, it will evaporate into up to 15 grams of xylosine powder. That is a lot of powder that you can put in a dope bag. A dope bag contains on average 100 milligrams. You can imagine how far you can stretch 15 grams. That is the main reason it is happening. Now, in the long term, it doesn't make a lot of economic sense. I think suppliers are actually shooting themselves in the foot with the introduction of xylosine. We can come back to that in a second. But I just wanted to emphasize that this is a mostly supply-driven phenomenon. Xylosine wasn't a consumer-driven phenomenon. It wasn't that people were demanding that suppliers transform the supply in a specific way that led to the transformation in the supply. But in some ways, xylosine is not only bad news for the person who uses opiates on an everyday basis. And some of the reasons for that is what I'm about to present. So one person named Tom that used both opioids and meth on an everyday basis began to describe to me the differences in the heroin high versus the fentanyl high versus the fentanyl drug high in ways that I think are very insightful. So I just want to read this out loud and then go over it so that you get a feeling for what I'm trying to say. So Tom said, fentanyl is such a short-lived high. The first thing he does is complain about fentanyl and how short-lived it is. It's such a short-lived high that the high, it's a good high, but it's so short that the nod is over real quick. The nod is that blissful experience of relaxation where a person begins to fall half asleep from an opioid high. The nod is over real quick and you get sicker faster. You get dope-sick fast. This is a problem for the person who takes opioids on an everyday basis. See, the tranq extends the high. It gives the dope more of a heroin effect. It's a good rush with the heroin-like legs. Legs is a word that is commonly used to describe the duration of the opioid high. But they straight put bags out there that are just all tranq. You shoot it, you feel no rush. Tranq fent is like you shoot it, you get the rush of the fentanyl, then the tranquilizer comes in, you nod, and you fall asleep. A straight tranq bag is like you shoot it, you get no rush, you're sitting there for a second talking, and then you're waking up two to three hours later in a weird position. Like one case, I lit a Newport cigarette. I shot a bag with a Newport. I woke up with a hole of Newport burnt into my stomach. You could literally drown in a half inch of water if you did a tranq bag and you fell out. This was early 2021. Look how insightful and sophisticated this understanding of the minute differences between fentanyl, heroin, and xylosine already was. Look at the multitude of new jargon terms, tranq fent, for the combination of xylosine and fentanyl. It's interesting because this passage is very nuanced. There's an acknowledgment of both the advantages and disadvantages, the pros and the cons of each one of these substances. Fentanyl gives you a good rush, an okay high, but it's very short-lived. The tranq gives the fentanyl some legs, which means that you don't get dopesick as fast, which is great because people don't want to be dopesick. Dopesickness, withdrawal, as you know, is a torturous experience. If there's something that staves opiate withdrawal, staves off opiate withdrawal, that is clearly going to be a good thing. But he's also acknowledging other problems with tranq. Number one, it gives you no rush. It's an important thing. It means that you can't just do tranq because you're never going to get those initial 10 to 20 seconds of euphoria that people really enjoy when they're using heroin or fentanyl. Also, it makes you just pass out. It makes you just fall asleep. That introduces a whole host of new public health challenges. You can burn a whole of cigarette into your stomach. You can get robbed. Women in Philadelphia are reporting much higher rates of sexual assault. It's a completely new harm reduction landscape compared to the landscape of opioids alone. In this slide, I want to spell out that some of the reasons for xylosine's staying power do have to do with the ways that it compensates for the problems of fentanyl, for the limits of fentanyl adulteration, for the ways that fentanyl is worse than heroin. The transformations that fentanyl brought into the experience of opiate consumption that made that experience worse than the experience with heroin before. Xylosine extends the length of the high, or at least staves off withdrawal symptoms. There's some ambiguity there that I think hasn't been fully elucidated in research on this. Is xylosine literally extending the opioid high, or is it just staving off withdrawal symptoms? Is it keeping you well for a longer period of time? I think that the truth is the latter, staying well for a little longer. When xylosine is present in low concentrations, not high concentrations, many people who use drugs say that it has brought back the nod. Often people complain that fentanyl takes away that blissful holistic full body embrace that involves falling half asleep, and that xylosine in low concentrations brings it back. In high concentrations, xylosine just makes you pass out and becomes bad. But in low concentrations, people often appreciate the experience of sedation that compares a little more to the old heroin high. This is another important point, by the way, that I think has not received enough attention among harm reductionists or even researchers. How is the experience and the public health concerns related to xylosine in high concentrations different from the experience and the public health implications of xylosine in low concentrations? I'm very interested in upstate New York because some of the data seems to indicate that even though xylosine is highly prevalent and increasingly prevalent, it's present in lower concentrations than in Philadelphia. Philadelphia is a great place to study xylosine in high concentrations. I think upstate New York is a great place to study xylosine in low concentrations. It's likely that the public health implications of one and the other are very different. It's likely that xylosine in low concentrations is much less dangerous, much less likely to produce wounds, much less likely to produce the deep forms of sedation, people falling asleep on the pavement in public, exposing themselves to all new kinds of dangers. But that hasn't even been asked by public health researchers, as far as I know. This is a potential new area for both harm reductionists and public health researchers to go into. One very interesting finding in Philadelphia has been that among people who die of fatal overdoses, the proportion of benzodiazepine detections has fallen almost at the exact same time that xylosine detections has risen. So this data suggests that there was a period of experimentation between 2016 and 2017 where suppliers were trying to figure out which additive was better. Benzodiazepines or xylosine. Xylosine seems to have won that battle, for now. Xylosine detections rise exactly at the same time that benzodiazepine detections begin to fall. Now, I've mentioned the ways that xylosine compensates for some of fentanyl's deficiencies, some of the advantages of xylosine, but it's also very important to keep in mind, and this is ultimately the reason why we're here, it's also very important to keep in mind that xylosine also introduces a whole host of new health challenges and harm reduction problems. I'm going to skip the first one for a second because this will get us into the question of the relationship between xylosine and overdoses, and that's going to be a very long conversation. We're going to go back to it, but so the second point, you know, the most important challenge of the xylosine era has to do with the emergence of this new type of skin wound. This is really that public health crisis of the xylosine era. We're going to talk a little bit more about that, and of course Liz's workshop is going to focus exclusively on that. As I mentioned earlier, because xylosine produces this kind of deep sleep, xylosine increases the risk of sexual assault and muggings when people are homeless and consuming in public. People are falling asleep on the pavement for long periods of time in very awkward positions. And also the question of withdrawal and the potential differences in fentanyl withdrawal versus combined fentanyl xylosine withdrawal is a new public health challenge, right? In Philadelphia, there is unanimity among people who are homeless or unhoused and use drugs that they don't want to go to the hospital anymore or to the clinic anymore. Because if they get taken in for the treatment, for example, of a xylosine wound, they will often be given something to treat their fentanyl withdrawal, but they won't be given anything to address their xylosine withdrawal. And they all insist that this is a very different experience that's also torturous and that they don't like that that issue remains unaddressed in hospitals. And xylosine withdrawal is not yet recognized as a medical condition officially. So this is a new issue that's also compounding already existing problems with access to health care, right? People who need to go to the hospital are not going because of the lack of recognition of xylosine withdrawal as a problem. So the wounds. There is a lot of research going into this. The biological mechanisms behind the formation, causation of these wounds have not been fully elucidated. Every month there's a new article revealing a new set of causes. But the ones that are currently dominant, the hypotheses that are currently dominant in the literature are, well, number one, that xylosine is a vasoconstrictor. It restricts the flow of blood and oxygen to the skin, and that results in the death of skin tissue. This leads to a form of wound that is different from a traditional heroin abscess because it doesn't necessarily begin as an infection, right? An abscess is an infection. A xylosine wound is just a wound, literally like a cut, right? Very often if a person is unhoused and doesn't have access to showers or to health care will become an infection. Will become infected. And that is a significant concern, but it doesn't originate as an infection. Once a wound, a severe wound develops, people can get into a kind of vicious cycle. And I'm thinking predominantly of the unhoused folks who inject drugs in Philadelphia that I work with. Things might be different in other cities, but the folks who I work with tell me that they often begin to re-inject into the wounds. And I've spent a lot of time trying to understand why it is that people re-inject into the wound. Initially I thought that it would be like a local anesthetic kind of thing that people were injecting in order to provide pain relief to the wound, which can be painful. But when I began asking people, and at this point it's been hundreds of people that I've asked this question to, the great majority say, no, Tylosine is not a local anesthetic. It's a general anesthetic. It will put you to sleep, but it doesn't provide relief to the wound. And so then I asked, why is it then that you inject into the wound? And people give generally two reasons. The first is that people are cutting their losses. They already find themselves with one limb at risk of amputation. One limb, like an arm or a leg, already looks ghastly. They don't want to put another limb at risk by injecting in a different location. So they're kind of doubling down on the location in their body that's already harmed and exposed. The other thing is that often the scar tissue, the black necrotic tissue, will fall off and reveal a new vein. And the thing is, because Silasine is a severe vasoconstrictor, people lose access to their peripheral veins in their arms and their legs very, very quickly and begin to have to inject into more non-traditional locations, like their neck or their femoral vein. I had never seen this in Philadelphia, by the way. When I lived here between 2008 and 2012, it was the height of the powder heroin era. That was a very generous substance. People very easily accessed their veins. People didn't have trouble achieving a successful injection. I never saw somebody injecting their neck or their femur in that era. Now you see that all the time. It's a very common phenomenon. That is a product of Silasine's vasoconstrictor properties. And so the fact that the wound will often reveal a new vein is another reason to inject back into the location. The wound will often reveal a vein and a person will have access to a vein for the first time in many months. Now one thing that harm reductionists still debate me on is whether people who only smoke are developing the wounds. At this point, I've talked to dozens of people who only smoke in Philadelphia. Not a single one of them has developed one of the very, very severe wounds that people who inject do develop. I don't only talk to people. It's not just a question of self-report. I see I'm standing right by them when I'm doing fieldwork and when I'm working with them. I see their bodies. I see their legs and their arms. And I don't see the wounds that the people who are injecting do develop. So smoking seems to be protected in that respect. People who exclusively sniff do develop very severe problems in the respiratory tract. They talk about pieces of flesh falling off of their nose every so often. These are likely scabs in their respiratory tracts. And now because of silazine, there's transformations in the use of stimulants among people who use drugs. Silazine is such a deep sedative, especially when it's present in high concentrations like in Philadelphia, that many people report using more cocaine or crack or methamphetamine to alleviate their sedation, to be more energetic and not just pass out. And stimulant use has always been linked to the phenomenon of skin picking, the compulsion to pick your skin. It's definitely a behavioral contributor to the skin wound issue. And again, clearly, I'm not judging people for engaging in these practices. These are the phenomena that are happening as a result of all these structural issues, prohibitionism, lack of access to health care, the lack of a regulated narcotics market. We had all those things. None of these phenomena would be public health challenges. Oh shit, I'm sorry. I meant to show you a photo. I'm sure you've all seen what a silazine wound looks like. But I wanted to show you a photo that I took a few months ago in Philadelphia, just to give you an idea of what a common trach wound looks like in a place like Philly, right? Often I'll go to a place where silazine is present in low concentration and people think they've seen a trach wound. They kind of have it. So I show this photo kind of just to really bring home what a common wound looks like, right? And I apologize to those of you who are squeamish, but this is what a common trach wound looks like, right? In Philadelphia, there's a slang term. These wounds look so much like burns that people call these wounds trach burn. This is the term people used to refer to these kinds of wounds, trach burn. Now the question of silazine withdrawal, this is yet another area of emerging research among harm reductionists and clinical researchers. It has not been well-defined in the literature. People generally report anxiety, insomnia, deep dysphoria, a lot of symptoms that overlap with opioid withdrawal symptoms. They are somewhat similar, but especially the phenomena of dysphoria and psychosis seems to be very specific to silazine withdrawal. There's a term in Philadelphia also, trach trance, for the specificity of untreated silazine withdrawal. When you go to a hospital, you get taken in, they give you buprenorphine to address your fentanyl withdrawal, but they don't give you anything to address your silazine withdrawal. They call that trach trance here. At this point, it's dozens of people who have said this to me. I would have to see a lot of data contradicting it for me not to believe it. The best literature on this right now is coming out of places like Camden that have a lot of experience treating combined fentanyl and silazine withdrawal and are now proposing novel protocols for the treatment of combined fentanyl and silazine withdrawal. I always refer people to this article by Herman Dupre, a doctor in Camden. This is only the first six days of the protocol that they propose, that they used to treat a patient who came into the hospital for the treatment of a trach wound. The article actually offers an 18-day protocol for the treatment of combined fentanyl silazine withdrawal. I think it's very thorough. It's just one case study, so it's not going to change medical practice in the United States unfortunately anytime soon, but it's the most thorough description of treatment of this type of withdrawal that I have seen yet in the public health literature. Very happy to give you the link also if you want the link to that article. It's available on PubMed for free. I might have to skip this so that we have enough time for the other stuff. It's important to bear in mind also that the novel prevalence of methamphetamine, some of the reasons for its staying power are similar to silazine staying power in that it compensates for some of fentanyl's deficiencies. People in Philadelphia tell me that meth also, especially the first time you use it during the day, staves off opioid withdrawal symptoms for a little bit. It gives you the energy to go and find more money to buy more opioids to prevent opioid withdrawal. That's one of the reasons for fentanyl's newfound popularity in places like Philly. Thinking overall about the public health impact of all these transformations, the emergence of fentanyl, silazine, and methamphetamine, and the rise of stimulant use in conjunction with opioids throughout the Northeast, I think that the story is going to be complicated. The impact of all these transformations of, for example, HIV and hepatitis C risk among people who use drugs is going to be much more complicated than the story of the impact of heroin alone. Heroin was almost easy. Silazine and methamphetamine have a lot of countervailing effects. Silazine interestingly, in staving off withdrawal symptoms, is leading people to consume much less opioids than they used to. This is something that I'm now investigating both qualitatively and quantitatively in Philadelphia. People generally are consuming up to a fifth of the amount of bags of dope than they used to before the emergence of fentanyl and silazine, again, because silazine is helping to stave off withdrawal symptoms, so people don't need to buy again. They don't need to reuse as much. That's likely to have a protective effect because that means that those who are injecting are injecting fewer times throughout the day. On the other hand, because silazine is a vasoconstrictor and leading to very quick vein loss, people are having to poke themselves many more times in order to achieve a successful injection. Even though people are injecting fewer times throughout the day, they're poking themselves many more times each time they do inject. You can see how it's like a contradictory impact, when silazine in some ways is somewhat protective and other ways it's harmful or elevates risk. The emergence of methamphetamine is clearly going to increase many health risks. Methamphetamine has long been associated to higher HIV rates and hepatitis C rates. It's important to keep in mind that the rise of psychostimulant use is a nationwide phenomenon. Psychostimulant overdose deaths are rising, are climbing everywhere in the nation. Now I think we should stop there. One thing I do want to talk about briefly, and maybe Lizzie here will be able to complement my own knowledge on this, is the relation between silazine and overdoses, because this was a subject of heated debate for some time. I think the data is still somewhat inconclusive on it. In the public health and the journalistic literature, people tend to over-specularize or over-scandalize. People sometimes rush to associate a new substance to an increased risk of fatal overdose. That's not always the case. The relationship between silazine and fatal overdose, the causality there is not clear at all, and it is very likely that silazine actually has no impact on the risk of fatal overdose. There's a good article, for example, by Jennifer Love at Mount Sinai that looks at emergency department data from nine hospitals throughout the country, and they find that people who arrive at the hospital following a non-fatal overdose, those who show up positive for silazine have lower odds of falling into cardiac arrest or going into a coma than people who show up positive for fentanyl alone. People who show up positive for silazine have lower odds of dying than people who show up positive for fentanyl alone. The hypothesis there, it's only a hypothesis for now, is not that silazine has any protective magical characteristics. Clearly, it doesn't. The hypothesis is that suppliers who are using silazine are using less fentanyl, and that's a protective effect. People who are using dope bags that contain silazine are using less fentanyl. Also, as I mentioned earlier, because silazine staves off withdrawal symptoms, people are using fewer bags throughout the day, and that's another way in which they're using less fentanyl than they used to before trying. There's two ways in which silazine can be protective, not because of the biological magical property, but because of what changes it's causing in the supply, which is really interesting. Not everything about the silazine era is bad news. Some stuff might be good news, and we can leave it at that, and I look forward to your questions. Sorry, by the way, about my hoarse voice. I hope I'm not too difficult to understand. Thanks so much, Fernando. Well, we've had great discussion throughout. Any other questions? Ariella has a question. Hi. Sorry. I've been watching a toddler while listening. Thank you so much. Awesome presentation. I've got two things, and I may have missed this earlier. You said that really virtually there is no heroin in the supply right now, that all you're seeing is fentanyl. Did I catch that correctly? Yes. I mean, I can give you some nuances around that, but overall, yes. Crazy. Crazy. The other thing is we hear a lot about silazine and fentanyl being an adulterant in other drugs. You were going to talk about pressed pills, ketamine. Can you touch on that really quickly, because there's a lot of emphasis in my communities about testing, testing drugs. Is this overkill? Are you actually seeing that? Thanks. Thank you for that question. That's great. Yeah. I do think it's very important for us to democratize drug checking. I think every locality in the country, every city, town needs to have a robust drug checking program that lets you know the exact composition of the supply and how it varies across time. We don't have that, right? That's inexcusable. This is a rich country where that should be possible. Hi. Cute baby. I love that. Cute baby. I love that. We need to know, not just qualitatively, which substances are present, which is kind of what fentanyl test strips and silazine test strips and nilazine test strips allow you to do. We need mass spectrometry that allows you to determine what percentage of sample is silazine, percentage is fentanyl, and everything else, right? Yeah. To respond to your first question, I have my own drug checking program. It's very small compared to all these official, very well-funded programs across the country. But out of the 300 samples we have tested, one had heroin as its primary component. None of the others had even a trace of heroin. And that coroner that supplied that one bag of heroin supplied a new bag the following week that was fentanyl and silazine. So they clearly don't have a consistent supply of heroin. It was probably a fluke and they probably didn't even know that they were selling heroin themselves. Pills are very interesting. I think pills, especially those that are available on the street, need to be tested thoroughly everywhere in the country. We haven't been able to find a lot of them, but the one is Sanex we tested had a little bit of cocaine, a little bit of silazine in it, which is bizarre. Also, it was not Sanex. It had this new benzodiazepine bromazolam. It's not new, but it's newish in the street supply. And because it's not regulated, it's not restricted, sorry, it's not scheduled, it's increasingly popular in the street supply. We've seen a few dope samples that had bromazolam in them. We still haven't gotten the full quantitative results, though, so I wouldn't be able to tell you how much of all these substances were in the supply. But it is important to be particularly vigilant about the press pill market and just the street pill market overall. Thanks so much. Yeah, absolutely. Thank you so much. One question, please, Fernando. How do you work your drug checking? What are your hours? Well, the thing is, it's not a program like others that are available in the country, like the one that On Point runs in New York City or the Stab runs in Ithaca. They have official programs that people can use. We go out to find the samples ourselves with the help of people who use drugs. You know, we work with Savage Sisters in Philly. They're our main collaborators. Me or folks at Savage Sisters who are collaborating with Savage Sisters participants to get the samples. Yeah, we do share all the information immediately with Savage Sisters. They have like a direct line of communication to the lab that is testing the stuff. And then Savage Sisters reports the info to their participants. They have returning participants that come back every week for showers and for wound care. They dedicate themselves especially to wound care. So they are able to share that info with folks. But it's not like it's not like an official program where people can come in at specific hours. Yeah, thanks for sharing. Well, that's all I have. Any other questions before we let Lizzie take it away on the more clinical aspect? I have a question for Nato. Thank you for working through whatever you've got going on over there. I appreciate it. Do you based on the years of experience that you've had doing this work so far, do you have any predictions for where Philadelphia specifically, but on a wider scale, like the rest of the U.S. is kind of headed? Yeah, it's extremely hard to predict, right? Things will happen, but you know, one interesting thing about xylosine is that it's leading drug corners into an economic crisis. And this is where the study, where the work with people who sell drugs is very important because it does provide critical public health information that you wouldn't get from the world of people who use a loan, right? So the people who sell who have been my neighbors for many years tell me that not only has the price of bags decreased, customers are buying much less than they used to, right? So it's not working out in the longterm as an economic transformation, right? It looks at the wholesale level as though xylosine is going to be more profitable because it's cheaper than fentanyl, the wholesale level. Then your customers are buying much less. So there's this debate going on that might eventually lead to the elimination of xylosine, the local supply, you know? But even here locally in this very concentrated world that is Kensington, it's hard to predict how things are going to play out. So I struggle with prediction and I don't want to be, you know, I don't want to, I'm not confident enough to tell you exactly what's going to happen, right? Luckily, many of the temporary transformations that happen, you know, like the emergence of nitrosines in some place or even the emergence of new analogs of fentanyl that are more potent than fentanyl alone, those seem to always be very transitory, very, very temporary. Like that drugs that we have been testing are ultimately very consistent in that they're just fentanyl xylosine in relatively consistent concentrations. Thank you. All right. Thanks, Fernando. So I'm going to share my screen. That's okay. All right. Y'all can see what I'm seeing. Okay. So I'm going to be talking about wound care. There is going to be xylosine specific wound care stuff, but also what I'm trying to capture but also what I'm trying to convey is just like, how do we just make sure that our services are available and that we have a constant or consistent supply of supplies to give to people and that we have consistent services that we're offering people. And then really when it comes to these more like challenging questions of what to do when you see this kind of wound or if it's progressing like this, that is where I'm hoping that, well, I should say, so the work that I've been doing at the state level here in Maryland, I am based in Baltimore, but is trying to do both non-medical people. So a lot of our peers, just our staff in a harm reduction organizations, just anyone who's like, I don't have a medical degree of any sort. And then, so training them as well as training the medical staff, but a lot of it overlaps and it just turns into a few more like detailed questions when it comes to talking to medical staff. So really just trying to make sure that we are offering services and seeing like who shows up and what we're seeing for that. Because yeah, right now we're talking about xylosine and all the previous pre-xylosine skin injuries that you used to see or still see, but we don't, just keeping an eye on what are we seeing and how to treat that. I guess my first question is, what are you all seeing wound care wise and what kind of services are your teams doing? Well, let me just say that I know that our providers in New York State, throughout New York State, downstate, upstate, are seeing some of these, what they believe to be xylosine related wounds. They are looking for this training. And so I know that our providers are seeing these. To go to Fernando's point, I don't have a good sense of like the severity compared to what we saw in the Philly slides or the rates of incidents compared to other locations, but we certainly are seeing it. Okay, awesome. And when, what was I gonna say? That we just wanna make sure that when we're talking about wound care, how I'm gonna basically do it today is I'm gonna talk about the hands-on portion and how to do that just so we don't lose time and then we can go into the details of like what drainage looks like, what that might indicate and whatever. But just making sure that along with any other services that we're offering people who use drugs, that skincare is one of them, making sure that maybe we're not just using the terminology of like, hey, do you have a wound? Not that you guys would ask in that certain way or that tone, but just being like, do you have any areas of concern? Is there anything that's out of the ordinary? Is there a thing you can't reach that you want me to look at kind of thing? I even like had made a poster for one of our health departments that has a, not a health department, but organization that has a lot of traffic coming in and a considerable amount of people that are unhoused in their community that they can tell that they have wounds or smell or whatever. They just have like a poster of all sorts of different things when they say wound or skin injury, this is what they mean, right? From like something tiny that looks just like a bug bite to something that might be what Fernando showed us. So really trying to make sure that we're not limiting how we're asking our questions so people can feel more open to like saying, yeah, I actually do have something that I'm a little bit worried about. Let me show you. All right. Fernando already gave a shout out to the opioid response network. This is what that is, just shouting it out. And then you all know how you, Chris, know how to contact Emily or Catherine. Sure do. And let me, just in case it's useful. So point of context, there's a local, in Troy, we have a street outreach that does meals on Thursdays. And so some of the folks, as you can imagine, are people who consume substances. And so part of what we're thinking about is to bring this sort of level of care if we can. And another question that I just wanna get out there is in terms of for physicians or other providers, in terms of insurance or liability for street outreach, outside of the regular kind of treatment system. So yeah, just wanna front load those questions, please. Yeah, and again, just to say, cause I don't know if it was recorded earlier, is that these are discussions that are being had by all sorts of people providing care. I only really know the East Coast right now, but is the normal ways that people that are already providing some kind of medical care probably already like have those little like asterisks or disclaimers of just being like, okay, I'm offering you basic services right now. I will be here Monday, Tuesday, you can come by. We're gonna try to keep an eye on this. We're gonna have these supplies, which we can do a lot with a little. But if you have any of these symptoms, right, that might be indicative of like a septic infection, a full body infection. Or if I'm seeing like exposed structures on this wound, I'm gonna suggest that you seek a higher level of care. Maybe you guys have the staff to be able to support people when they are seeking a higher level of care to help them navigate or be there with them. But just letting them know, there are limits to what I can do right now because maybe in the space that you all are in, the funding that you have, maybe nobody is wound care certified or has a higher level of degree where they can address prescribing antibiotics if need be or doing the debridement if need be or prescribing other things. So whether that's in the area that you're providing care, that there's just a general poster, or maybe that's something every time they have a conversation, a lot of the infographics will have what to look for for an emergency, but just letting people know that wounds, our skin health is dependent on so many things than just what's going on topically, right? What's going on in that one area. And it is beautiful that it's being coupled with like a place that's serving food, right? To be like, it is important that we address a lot of different things when we're talking about this one particular thing that's going on on your arm because these are reasons it might not heal. These are reasons that you might be having complications. So just building that in of just a constant reminder for people that like there are limitations to the services that we're providing you. And, but our services that we are providing can go a long way if we try to stay on top of what we're seeing, we try to do the best use practices, the best preventative practices for other things. Have you ever seen like, I don't know, I mean, obviously lawsuits or other kind of like, I don't know, interesting cases around this topic of liability in particular, yeah. Not interesting cases, just a lot of interest in making sure that people aren't sued. You know, like a lot of interest by those who are in charge of their nurses or their medical staff are running the organization that, hey, I don't want to get us in like legal trouble. Right, so that's where the signage you're suggesting that that is the kind of like, that's the first level of, and of course the regular discussions also. Yeah, and I can't remember if I said it earlier, but like, I just like proofread a paper that Johns Hopkins, a research team out of there has written up because they were doing like statewide interviews around wound care services in community settings and harm reduction organizations, as well as wound care being provided maybe in more like traditional settings, as well as like emergency rooms. And there is already a published portion of that, but this new paper that's going to come out is around just this general discomfort in all those places that I told you from the community level, all the way to the emergency room of either we don't know what we're doing because we don't know anything about like drugs that people are using, to we understand what people are using and have an understanding of what they're using, but we don't feel supported because we're working in a non-traditional space like harm reduction. And so it just feels like the whole wound care continuum is a gray area for so many people because everybody thinks like that the way to address a wound is to see it from start to finish and heal it and that it'll go away and never come back. And it's just not the case, right? Like we have such poor wound care services in all settings, you know, that it's been really hard. It's been interesting, but it's been really hard to figure out how do we provide this care? And I feel, I guess, reassured that Maryland is not the only state that hasn't figured it out yet. But working, like I said, I know that there are teams working with your board of nursing and that's just nursing, but in trying to make sure that the higher powers that be and that regulate us as nurses, for example, are aware that we are trying our best to help people in need. And it could be construed that we need a doctor's order or something like that. But the care that I'm talking about is such basic wound care and just your basic scope of practice when it comes to being a nurse, for example, that that care coordination and just having an eye on what's going on and being able to listen to a person talk about their situation, see what's going on with them medically. Maybe you're doing your little assessment and you can extract a whole lot of information, right? And you can give this person who might need a higher level of care a lot more legitimacy when I say, hey, I'm a nurse that works in this mobile treatment band. I've actually been seeing this person for the last year addressing this lower extremity wound. And I know it looks gnarly, but here's what we've been trying to do. Here's what I know that's also been going on in their life. And this is all, of course, if the person is willing to have you work as a team, but when people are seeking a higher level of care, this is so the emergency room doesn't think they just fell out of the sky with all these gnarly wounds and haven't been neglecting their care, haven't been caring for themselves, haven't tried to be doing any healthy practices. For us that are doing that work in the community of being like, we're just fighting, we're working in a world where we don't really actually know what's always being consumed and how people are using it and what they have access to. But we wanna let you know that we know a lot more than you actually do. And please let them... If we are able to be a part of somebody's care when they're going in and giving them help and saying like, hey, I'm a nurse and this is what I've seen, this is how I've been treating it, this is what they've been doing to take care of themselves. And I'm also gonna be here when they get discharged if they want me to be involved. So those kinds of things, I feel like just our basic principles of caring for somebody as a nurse. That's all very helpful. Thank you very much. Yeah. So yeah, we're gonna talk about skin stuff. That's how I'll put it. So like I said, we'll start with just like what I mean when I say basic wound care. And we will talk about xylosine, but just trying to make sure again, if our messaging can be very clear to people on your skin health and that if you are using drugs, especially if you're injecting to just regularly check your skin and just kind of know what's going on, right? There's always reasons for a million other things going on in our skin and dermatology is very confusing sometimes. But if we already know that something like xylosine starts off looking like this particular type of injury on our skin or just like a little dot, but then it has the, it's likely to grow or the little dot is likely to open up and we have exposed skin that maybe hardens on top or whatever, then hopefully people can address it at the start of that injury or take preventative measures. So hopefully it won't become something larger. So this is a slide where, right, we have the steps to wound care, we're looking at whatever the area is. This could be us looking at it as people that are helping someone with their skin issues, or it could be the person that has it. But we're just looking at the area. What does it look like? Does it have drainage? And then what are we gonna do to treat it? So all of these questions get a little deeper. And I think also a question that I always have is kind of like, how is the medical team or the people that are providing care, whether they're medical or not, if they're documenting at all? Because like, kind of like Fernando was saying is like, it would be lovely if we had all this drug checking across the country. We also really don't have an understanding of how many skin injuries we're seeing just because documentation in a community level is so hard because you're not connected to like the hospital level of documentation. And so it's really usually like place by place based. There's not a lot of conversation, right? Because a lot of harm reduction is like using a unique identifier. So we're not like having anything HIPAA compliant or causing any kind of issues with their identification. And that's not to say you need to document things in a certain way. But what we've been trying to do is really encourage if people are expressing that they're having these things, some kind of documentation of like, okay, we've had five people that have had this kind of thing. But if you're treating a wound and you're trying to like watch how it's progressing, I think that you would have a little bit more documentation of just like where it is, what it looked like, maybe. What I've been telling people is like the people that are using drugs, you know, an easy way to keep track is, you know, if you have a phone, which a lot of people do, that have a camera on it, you could take a picture and that gives you kind of like a timestamp, right? You know, what date and the time is. So if you're like, is this getting better or worse? I can't tell, it's been a week. You can look, you can take another picture and compare it with the last one that you had. Or, you know, people have like a marker or something, but just keeping an eye on the wounds and just making sure that people know that like they can do their own tracking. So when we talk about this very basic way of treating wounds or treating areas that are open and need some kind of love, we wanna make sure that, you know, there's a million and one wound care supplies. And the basic principle is the same, is that we wanna clean it, we wanna keep it covered and we don't wanna mess with it. And so when we say keeping it clean, we'll show that it, you know, that could be like basic water that could be just like brushing off some of the dust or something like that. It could be like nice little like lathering it up with some like gentle soap or just basic soap and washing it off if people have it, pouring a water bottle on the area. So cleaning, it doesn't have to be a particular way. It's just trying to like give that area maybe a little like breath of fresh air in the sense that you are, there's usually like a, just a gummy layer, whether it's actually sticky or not that they call like the biofilm that just like hangs out on top. So when we like wash something and we say like, wash like you're washing a baby, you know, like kind of a soft scrub, it helps like just bring blood flow to that area. It helps remove that kind of grimy layer to allow those new areas to like surface and maybe get better blood supply and get rid of some of that film and have a better chance of like coming together to heal. So cleaning it, but cleaning it could be just water, could be no water at all, depending on what the person, where they live and what they're going through. And then this contact layer, which is the blue layer. And so it says like Xeriform or honey or petroleum jelly or A and D ointment. That contact layer, whether it's a wound that's draining a lot, right? We have wounds that like have a lot of drainage. We have wounds that have some drainage. We have wounds that are dry. We don't want to worry about, we can't put a contact layer because it's already like goopy, right? So that's why I like the importance of like, maybe I poured a water bottle off and kind of like patted it dry, is that now you have a surface where maybe you've removed some of that extra drainage. But just putting a light layer of like A and D ointment or something is going to be able to give it that little bit of moisture but also make sure that that absorbent layer, the little tan layer, doesn't stick directly to your wound and become an issue when people are trying to change their wound, right? So that contact layer is just a little buffer zone and if a wound is really dry, right, you could put a little bit more A and D ointment or petroleum on it and then put a layer on it to cover it. But if it is a goopy wound, you could put that little layer of the contact layer of some kind of ointment and then you're putting that absorbent or absorbent layer on there to absorb all that extra drainage so it's not just hanging out on the skin and breaking down around the wound. And then that outer layer is just securing, right, keeping that area in place. And all of that is important. It seems like a lot but it should, you know, all of this dressing stuff could take less than two minutes and should be easy to teach somebody. But the hope is that we're not leaving this area that needs a chance to heal exposed to the elements, the propensity to be dried out if it's not covered and has like a moist warm environment. And then, you know, if we have something, whether it's a smaller bandage, whether it's a larger bandage, you know, that's also a mental reminder that that's a deterrent, hopefully, maybe not. You know, maybe it'll be less itchy because it's warm and moist. Maybe you're less likely to take off the dressing because you're like, I don't want to bring back the smell that was underneath there or the dressing looks so pretty. I've suggested, this is very common in the hospital setting, but like, you know, whenever we change a dressing in the hospital setting, we have to date it with our initials and like the day and time. And that's a good practice, even in the community level, because, you know, you can write when you changed it or when, you know, maybe the person has a Sharpie and they're changing their own dressing. And then when it's time to change it again, right, those mental reminders, or maybe I see somebody every Tuesday, and I just write on there, oh, I'll see you Tuesday, July, you know, 11th or whatever. And they're like, oh, okay, yeah, that's a good reminder. But those are the simple layers. Here's some of the supplies that I was talking about when it comes to cleaning, covering, and keeping it moist. So you'll see in like that far left, right, we can look, we have like a little wipe, I think the top one is one of those like little towels, maybe that's what it's showing. When you add water to it, the towel like expands and you can use it to like scrub. Little saline bullets, I know a lot of places like really spend a lot of money on getting saline bullets to use as wound cleaners. And they're fine. They're a little more expensive than you would need, you know, you could just hand out a little bottle of water. It doesn't have to be saline. But I know that saline can double as like other useful things and people's drug use. So there's no issue with it if it works out best for people. That blue container, the Vash at the bottom, it's very expensive. There's all sorts of wound care cleaners that, you know, talk a big talk about like decreasing the bacteria burden and all this stuff. Most people just don't have the budget to buy them and therefore like we don't talk about them being necessary. But it might be something if they are going, if they are working with the wound care clinic or some more established place on regular wound care, they might use that. But most of the harm reduction settings are not really using that because even when places have bought them, they're being used incorrectly. And that's a big thing, right, is that these wound care supplies, there's so many of them that like you could, you know, stock it, but then you're going to just end up like getting people who are really married to the idea of this product is the only product that will help me, which is just not true. And that's just a good reminder because we had an organization that they went so long without a nurse and then they hired a nurse and then they had a nurse for about a year and then she moved on. And so then they were like, we have all these people that she was seeing that they were freaking out where they're like, I have to have the nurse and the nurse gave me this and that. So we really had to like kind of decondition the participants they were seeing to be like, actually, this product is just as good as these products. This thing is just like this thing. But that's just human nature, right, to like be like, I think this skin care product is going to take away all my wrinkles and not this one. So we talk about that contact layer, we have xeroform at the top so that yellow like petroleum impregnated gauze, which is nice and easy to use. Also not necessary necessarily. You could use some gauze from the other column as and put some A&D ointment on and you would have a similar effect. The, sorry, the xeroform is just easy because you're opening it up, slapping it on kind of thing. And then meta honey too. I know some people really feel strongly about meta honey. It is also not a product that's necessary. It does have great properties. I know that especially Jason, this other wound care nurse that I know and work with, you know, this time of year, stuff like honey, meta honey, could, it being hot, could, you know, attract bugs to an area of people are, you know, unstably housed or just are spending a lot of time outside. So, you know, the less sugar on our skin to attract bugs would be better. And then the dressings are really basic, right? We have gauze, we have these A&D pads, which are just kind of like glorified surgical maxi pads. But, you know, these gauze pads at the top go, so they stretch so far, right? Because you can use them to clean an area. Then you could use them to put A&D ointment on and, and put directly on the area. Then you could take a few extra of them and put them on top of that to be an absorb, absorbent area. And then, you know, you could so they really are such a multi-use tool when it comes to like wound care. Also, when we talk about like how do we, maybe we have a patient with a lower extremity wound that has a lot of drainage because they have like a lot of edema, a lot of swelling at the bottom of their legs. When we're talking about getting creative, we could use like a maxi pad or a diaper, right? On that area, if we're needing to absorb a lot of moisture. So just making sure we're not limiting how we're thinking about what's the best product to use. And maybe, you know, this person is not a regular, so you could have something where you're like, Hey, if you don't come and get this, you can also buy this at the store. And this is easy and a lot more affordable than like some fancy pants, a wound care supply. And then we have the Coban and the Curlex. Those are two secure, pretty straightforward. So Curlex is just like rolled gauze to roll around the area. You don't need to use the whole roll, you know, really trying to teach people to stretch whatever products they have. And that Coban is like stretchy gauze. The only thing is you don't want it to be too tight on there. But it's nice. Because the Coban can be reused if needed, if it's not soiled or anything like that. And I think of it as kind of like weatherproofing the area because it gives that security to the area where if I have someone who's putting on and taking off their jacket a bunch, I don't want whatever dressing I did or helped them do for themselves to come off as soon as they're taking off their jacket or their shirt. So making sure whatever we're doing is not too bulky, that it's not too hot, or it's not causing them not be able to put their pants on anymore, socks or shoes on. So really working with the person to be like, is this comfortable? Is this doing what it needs to do? I believe you all get a copy of this presentation, right? Okay. I'm not going to go over all of these products. That's why I say it. But it is a great slide in the sense that it's telling you what it's for and the cost breakdown. All those things that we just saw on the previous slide, really affordable and can go a long way. Some of them even come in cool colors, which is fun to spice things up a little bit because we know that nude color is not actually nude for everybody. This is another list of supplies. Great list. Very bare bones of what you need. All right. And so this is probably pretty self-explanatory, but the most important thing that we keep having to reiterate is wounds heal best when they're moist. And that's not usually the wording that we have to say. The wording is usually like, don't let it dry out. Don't just keep it open to air, meaning don't put anything on it because it, again, needs that moisture, a warm, moist environment to have more blood flow to the area, less outside interference from anything, right? Whether you were injecting in the wound or picking at it or it's drying out and it's itchy, so then you're scratching at it or so many times people will hit the area and then it'll break open again, which is super painful. So covering it to let it heal as well as covering it for all those other reasons. But I do like it. So if it's dry, we want to add moisture. If it's too wet, we want to decrease that drainage. If it's infected, kill bacteria. And if it's necrotic, we want to remove that dead tissue. Now this says at that bottom one, metahoney or debridement, those aren't the only debridement. People often think that that needs to be like surgical debridement, where they're like removing all the dead tissue. But thankfully, this xeriform, A&D ointment, and petroleum, those can act, this nice, warm, moist environment can act to really like start to loosen maybe that really rock hard eschar, which is the dead tissue, start to soften it. So maybe it'll like slough off a little bit. All right, wound care, education. So this is the basics that we're telling people, whether it's xylosine or not, is exactly what I said earlier is we're washing the wound, of course, wash hands, use hand sanitizer. This says change dressings every one to two days. That's not a law of any sort. That's not a wound care law. But, you know, especially depending on the reality of the person who is experiencing the skin injury or wound is like, what is going to be realistic, if it's draining a whole bunch, and like, you see the person the next day, and it's already like soaking through what you helped them with or what you saw them change, they might need to change it every two days. But for a lot of people, it's more of like, change it when it's soiled, or maybe it's been four or five days, whatever makes sense for their wound at that particular time, or just their lifestyle. You know, it says rinse with saline. Again, it doesn't have to be saline. We do want to keep it moist. We want to make sure it's covered, not too tight to cut off blood circulation. And then again, making sure that we're reviewing all those signs and symptoms that people might need to be seeking medical treatment for, which is so much easier said than done. We'll have a slide about sepsis and everything. But you know, a lot of people are balancing so many different feelings and symptoms on a regular basis. When they're using drugs, or when the times when they're not using drugs, but wish that they are, you know, had drugs in their system. So these people know their bodies. And so I think like, even though there's a lot of overlap in what they might be experiencing, that might be like, well, that could be a sign of infection, is just to keep an eye on it and be like, the worst case scenarios, if you're willing to go get it looked at, whether it's by somebody in the community, or whether it's going to the emergency room, like, if you're concerned, it's might as well go and get it checked out. And by you, I mean, the person that is has the wound or the skin injury. But those are good rules of thumb. All right, the do's and don'ts of wound care. Um, I think, you know, the biggest thing is, yeah, like, you want to make sure that whoever is talking, right, whether it's I am a nurse, then I'm able to do maybe more than the peer that you were just talking to, because of my like, nurse degree. But making sure that, especially if it's visible, right, that you're not just being like, hey, we have to talk about what's happening on your arm. Right? We want to just be like, um, just want to let you know that we have these services. And we have these supplies, like you want someone to look at it, maybe we have somebody on the staff that day. But feel free to take these supplies. And we'll be here these days, you know, just re reinforcing, these are the services, these are the supplies we have, this is what our schedule is. And letting people know all the time, and seeing if they seek help, or need help with it. I think that the skin issues that have been going on, especially of the past few years, um, you know, it's, it's awful, that people are experiencing these things. And it's been a real catch up for people in places to try to address them. But it is, I'm so glad there's so many places that are able to do it. And just knowing that, you know, take your time, this is not how I like to describe it is like, I worked with this one wound care clinic here in Baltimore. And, you know, we were just talking about like, hey, on a, an average person that comes to your wound care clinic with a wound that needs to be seen, no matter what the cause of the wound, what is the average amount of time it takes for that to be like, fully healed, healed and addressed? And they're like, average six months to a year, right? Which is a lot to think about if you're somebody that's experiencing any kind of medical issue, and you're like, okay, this is not going to get resolved for six months to a year after like, regular doctor's appointments are trying to address it. But I think it's a good reminder that like, these things are not going away overnight. And it is important to remind people that like, hey, this is a process, we're here for you. We're here to help you navigate it. But it might take a little while to heal, right? It might not happen overnight, despite you trying or, you know, like, you we know that you're still going to continue to use or they know they're still going to continue to use or something like that. But that doesn't mean that we can't try our best during that time. And just reassure people that like, this is not a reflective of you as someone who doesn't care about themselves, like these things are happening to people. And thankfully, a lot of it can be addressed in the community setting without having to go into emergency rooms for something like IV antibiotics or amputations or surgical interventions necessarily. Obviously, just establish a rapport. So that's what I'm talking about, which I feel like, like Fernando said earlier, it's, it's really easy to have these conversations with harm reduction organizations and people doing the direct services. You all just get it. You're doing it every day. So it's not like I'm telling you anything new. Also removing the dressing, when we talked about having that contact layer, and then that it could get stuck there, right? It could get stuck there, whether you have that contact layer on there or not. So it's always just going slow, reminding the person to like, if it feels like the dressing is stuck to that area, you can loosen it or soak it with water or saline or whatever, to start to like peel it off slowly. But wound care can hurt for sure. I think I need to move though. I was looking at my chat. Oh, is that right, Fernando? I can't tell. And then, you know, same with don't let it dry out, because it needs a warm, moist environment. Continually reminding people not to use peroxide and alcohol on the area. I, we've just been, I mean, I loved using hydrogen peroxide on my wounds when we were little. We would do it all the time as kids. So, you know, it's, it's definitely more universal than any of us thought, but just trying to avoid that for sure. All right. This is just important because, especially with something like xylosine, where these wounds are progressing fairly rapidly, if there's continued use or injury to the area, is that we're seeing, you know, these layers of the skin, we're seeing the underlying structures, you know, in a lot of the situations. But just knowing that, yeah, if we are injuring something, even our epidermis, right, like top layer of our skin, like that can be really painful in and of itself. But especially if we have these underlying structures that are exposing nerve endings, or messing with like the vasculature to the area, injuring like blood flow to the area, or like fat tissue, that it can really complicate not only the like, how the wound appears, right, but how it feels and what people need to do to actually interact or to feel better in the area, to make it look better in the area, and what products need to be used, yada, yada. This is usually what we ask the crowd, but what is the purpose of the skin? Um, since there's only five of us, we can just move on to this one. But we know the skin, the skin has a lot of different purposes, right? And we have skincare that's like, whether it's about a wound, or whether it's about wrinkles, you know, it's a very important to a lot of people, for so many reasons. Just general appearance, of course, is important for everybody. But, you know, it's protecting us from a lot, germs, hot, cold, sun, chemical, physical damage, the importance, right, of actually having sensation in your skin, right? It goes so far. And that it absorbs things. So our skin is miraculous. And it really stinks when it is compromised for whatever reason. Because we see how detrimental that can be. A good example of that is, you know, if people have diabetes, that may be uncontrolled, they might be having that neuropathy, where they can't feel as well in their extremities, or they might have like eye damage. And really, when we see that decreased sensation in people's feet, you, it is so quick for people to have something like ingrown toenail, or step on something or a little cut or scrape from hitting their foot, that really can get a lot worse just because they don't have that sensation there. All right. So you know, going back to like what I was saying about this wound care clinic telling me it takes about six months to a year to heal some of those more like serious wounds that are going on in the wound care clinics. Just important to remember that there are actual steps that happen with wound healing. And when wounds aren't healing, it's usually because it's stuck in a phase that it can't get out of for whatever reason. So it has number one, hemiostasis. So you know, just stopping blood flow or you know, stop the bleeding. We have our platelets that come and clot for us. And then we have that inflammatory where that's where our immune system starts to show up and is trying to destroy the bacteria. And like it said, infected wounds are usually stuck in this phase, right? Because we have it, whether our immune system is weak, whether the bacteria burden is either just continues to like introduce new bacteria, or it never gets fully cleaned and healed, that we can stay in that inflammatory area. So inflammatory, right, is pink, puffy, painful, maybe pussy, all that kind of stuff, because you still have your immune system showing up in that area being like, what did we miss? What do we need to do? So it's still an activated area. Then proliferation, you know, we start to make tissue, we start to cover up that wound, that matrix, the skin matrix comes together. And then we have remodeling or maturation. So trying to like really fully heal that area. And that's important to remember is that even when that area heals, it might not be the same, right? And I feel like this is research that's happening is to like really show that like, this area stays compromised for a long time. Even after it's like closed up, you don't have any open areas, and maybe it doesn't hurt anymore, and it looks fairly normal. It's still skin that is still needs a lot more time to like get back to the integrity of this, like the neighboring skin. So, yeah. Yeah, well, this is this is the end. Yeah, yeah. This is it. Yep. Please go ahead. Oh, OK. OK, so when we're talking about just looking at something and like what the heck's going on with it, we can think of like, is it look like it's kind of healthy and like we're moving in the right direction or if it doesn't look that healthy and we need to start like doing a few other things. So you can tell from the the slide, the epithelial and the granulation on the left side of my screen, you know, have that red color to it. Right. It's either pink or it's red and that's showing blood flow to the area. The epithelial is like that, like very like thin outer layer. And the granulation is like the layer underneath that's trying to heal. So those are good signs. You would say like, oh, OK, look, it looks I mean, you compare it to the other ones. Right. You see this like yellowy, greenish, creamy stuff over this pink, over the red. And then, of course, on the other side, the necrotic you see like almost looks like fish skin, but just this black like layer where you can't you can barely see anything underneath it. This probably looks like a knee or a heel or something like that. So just knowing that just because these two have pink or red on them and you're not seeing any of that slough or necrotic tissue doesn't mean that they don't need to still be covered. Right. And you still there still have time that they need to heal and be protected. And then the slough and the necrotic. If we're talking about very basic wound care, it's still doing exactly what I said earlier, it's, you know, cleaning the area. These ones might be good to use that that's lathering the soap a little bit and just kind of washing it for a second and then removing the soap and water and then adding it. But it's people get really tempted if they and by people, the people that like have the area and even some medical professionals about removing every bit of that. And that's where we want to give people like the messaging that it's like this will come off with time, but don't worry about removing it all right now. Don't worry about ripping off all that black stuff because you're going to cause yourself pain. You might be introducing new bacteria there. And the best thing to do is just to soften it and see how much moves off. And a lot of it can soften and remove itself eventually, if some of it's like pretty stuck there, that's where it can be an easy interaction with someone that is certified in doing debridement that could get it off and remove that area to be able to like expose the underlying skin to give it a chance to heal and look like this epithelial and granulation tissue. But trying to just make sure that people don't think that they need to like. Manually remove it with their fingers or scrubbing at it or pouring peroxide or alcohol on it, but just giving the area some time to get, you know, you can always say like in the time that we're covering and everything, like, you know, make sure maybe you're elevating your legs if they're super duper swollen to give a chance for like, you know, that that area is not put have a lot of pressure put on it from like all that swelling, making sure that they're eating and drinking and trying to sleep at night, all these things to help like will move the marker in the direction of more likely to heal than that. Well, speaking of more likely to heal and not, what are the things that slow down healing? We have a lot of things, right, and this is not an exhaustive list of things, but also important things when we're having those conversations of things people can do. Right. We want to empower all these people we're working with and be like, I as a nurse am important and there are things I can do, but there's so much that you can do and that we can help you with if you need access to these things or just a reminder. But, you know, things that delay wound healing, making sure they're using their drugs in the safest way possible. Soiled skin. Right. That would be like if somebody well, I think it's pretty self-explanatory, but. You know, are you able to change the area or even like rinse off the area? Obviously, showering is great or changing clothes is great. It's possible if somebody is advanced in age, you know, at least in Maryland, we're having a lot of. Older people having issues around their drug use, a lot of overdoses, fatal and nonfatal, but like, you know, there just becomes a lot more complications when they're using drugs in advanced age with just their advanced age. Smoking, what wrong wound dressing, no wound care, if they have any other medical conditions and conditions, and then, of course, we talked about poor diet and all that stuff. So. And that's just important to remember, because if the person's feeling frustrated or stuck, depending on what is going on with them medically, just to remind them that, you know, there's a tough hill that they're climbing to address all these things if they have like heart or lung issues or diabetes or other infections. So. Just trying to take step by step to give themselves a better chance of healing. This is what we would talk about, right, if people are either having issues in an area, whether it's you've seen them long term or you've seen them only once, but having those infographics or signage or just those conversations about what to look for, if a wound or a skin injury is infected, and to keep an eye on it and to make sure that if it does seem like it's infected. Either addressing it locally with the basic wound care steps, if it feels like they're doing that and it's still feels infected, that they are reaching out to whatever staff is available to them, readily available through your organizations. And then obviously, if it was a systemic infection, which I think might be on the next slide, then that does need medical attention, which is, again, easier said than done if somebody thinks that they're septic because, you know, I feel like we run across that all the time where we're like, you really need to go to the emergency room, right? And people are just like, I'm not going to go to the emergency room, which is a whole other, you know, talk that we can have. Um, so sepsis, right? Sepsis is that full body infection of the blood. This is an important slide. Even if, you know, again, some of these symptoms on this left hand side are things that all of us could feel on a normal day, depending on, you know, what we did that day or just what our health condition is. But if it feels out of the ordinary, and if it also, you know, it doesn't have to be associated with any kind of wound or skin injury. But knowing that sepsis can happen quickly, and it can become serious quickly. So, yeah, I feel like it's, it is hard to get people to seek a higher level of care, even when we're really worried that they might, their symptoms might apply to each one of those bullet points. Um, but just knowing that if somebody has a full body infection, that they need IV antibiotics, they need medical intervention, and that the onset can be pretty quick. Like, a full body infection can happen within like seven hours. Um, questions about this slide? I, I feel like in the previous ones we've talked about, people have had questions because they're just so worried about people not going to seek care, or when an ambulance comes, they don't get on it. Um, but again, it's just reminding people that especially if they are using drugs, and we don't know exactly what's going on with it, or maybe they inject, or maybe there's other things going on, if they are feeling like something's out of the ordinary for their body, and they're, they're worried about these things, or if you're talking to them, and you're like, you're having all these things, like this is what it could be, and yes, it's very serious, but thankfully, IV antibiotics and medical attention, like sepsis is something they're very used to treating, um, and maybe you can send support with them, um, but. I have a question for you here. Um, have you, if you did have someone who said, absolutely not, I'm not going for whatever reason, what are your next steps there? Um, just letting them know, and this is also a very, like, common question is, you know, letting them know why you're saying it, and saying, like, based on what you're telling me, and what you're experiencing, this is what I think it could be, this is why I, I'm telling you that I think you need to go, um, maybe this is how I can help you get there, or, or how we can support you, um, and how we can prepare you, right? Like, this is what you can expect, um, and, but if, if they don't go, they don't go, right? But you can just be like, this is what I think you need, because anything that I do right now is not going to address what's actually going on in your body right now. We're, like, what I have in my little, like, kit is just trying to address, maybe if you're talking to them about a wound, maybe they don't even have a wound, um, but just be like, I am really worried about these things, and you're telling me that you don't feel well, and you don't feel your normal self, so it could be that you need these things, and then they're making an informed decision, and which really stinks, right? I wish that people would receive care, and I wish care would treat people well, um, it's just so common that people don't initially, you know, seek care. Do you have another question? Is there, is there any benefit to, um, oral antibiotics, or is, at this point, is it just, like, it's too late, it's not even worth trying? Yeah, so I would say you're talking about prescribing it yourself. Yeah, or, like, telehealth, or just, like, just trying to think of ways that, if they're absolutely against going, is there anything else you could do, or just being, like, good luck? Yeah, so usually, oral antibiotics are just tricky, because, in the sense that, like, they could be getting these broad spectrum antibiotics, and, you know, like, causing their own resistance and issues if they don't take it properly, right, or they don't take the whole course. Um, now, thankfully, I know this, I don't know if this is the best time to insert it, but a lot of these xylosine wounds, and unless they are getting into that underlying structure, or, like, um, they can be infected, but a lot of them are not infected. Um, so that's good in the xylosine wound portion, is that it's usually pretty superficial until it's not, but even then, for whatever reason, it's not causing, um, infections, or soft tissue infections, like we're seeing, usually, with, like, an abscess, or injecting, um, with other substances that are causing skin injuries, um, that are usually from, like, maybe not using, um, sterile needles, or clean technique. Um, so, I feel like the most common, um, suggestion has been to not use oral antibiotics. Have you looked at, um, there is a document, it's, like, a 20-plus page document out of Philadelphia called Recommendations for Xylosine Associated Wounds. It has, it's amazing, I can share it, um, but it, uh, it goes over, like, the best practices for all of these recommendations for, like, sharp debridement versus, um, using, like, autolytic debridement, and then it does talk about antibiotics, um, and so you'll see that it doesn't really suggest oral antibiotics, um, but it's a great document, and I'll share it with you all, and it's accessible for anybody, um, if you look it up. It's, like, through the City of Philadelphia Department of Public Health called Recommendations for Xylosine Associated Wounds, um, and it has a lot of recommendations, um, yeah, absolutely. All right, next one, um, so types of drainage, um, this is just a nice little picture to say that not all drainage means that it's infected, right, um, that we get all sorts of drainage coming out of a skin area, a wound, you know, bug bite, anything like that, um, so people need, don't need to necessarily freak out or think that it's infected just because it's draining something, um, but you don't want to necessarily have a lot of drainage on one area, because then it becomes macerated, is, like, the medical term, but would just mean, like, the skin becomes, like, you know, just as if you were, like, in a bathtub for an extended amount of time, and your skin starts to get all, like, pruney and peely, the same as, like, if you have drainage that's just hanging out on, uh, the skin around the wound or even the wound, that it's just becoming, like, boggy, so that's why we say if it is draining something, no matter what kind of drainage it is, you could have that absorbent layer to be able to, like, pull up some of that drainage, um, I was telling you to describe it, so that would be sanguineous, serosanguineous, and that would be slough or pus, um, so this is just important because these can look alike, and a lot of people will say this is pus, you know, um, the most important differentiation is just, like, pus usually wipes off, um, you know, you pop this, and then you can wipe it off, slough is, it's really, like, it's tenacious, so it likes to hang out on there, it's not easy to get off, it doesn't need to be, you know, um, you don't need to get, like, tweezers or a cotton swab and just keep swabbing at it, um, but just making sure that you are cleaning it, putting that moisture layer on there to hopefully it gets softened and it just removes itself, um, but yeah, it, it can, if you have a bunch of slough that's just hanging out, again, what you're seeing under there is the possibility for some healing skin, right, you see the red and the pink, um, but you just want to get that layer off, and there are products, depending on where the person's going, that removes those things quicker, but they're not, um, that is not indicative that it, like, is super infected, it just means that that is getting in the way of the skin underneath, that healthy pink-red tissue, um, from being at the surface to be able to heal. Um, abscesses do exist, um, so, you know, abscesses are just, again, like, this thing shows you a ball of pus underneath a raised area of skin, um, when you are, when you're trying to, like, treat an abscess, the most important thing is to not try to open it up yourself or poke it and, you know, get all the pus out, which, I mean, Dr. Pill Popper is popular for a lot of reasons, um, because people love to manipulate, uh, whatever's going on on their body, uh, it is fun to do those things, I say that as someone who does them sometimes, and I get to do them on patients sometimes, um, but yeah, if we can just tell people, like, you know, a warm, compressed, or even just, like, keeping the area safe, it was, like, winter or something, like, making sure there's, you know, you're wearing a jacket or a sweater or something, and maybe that area will come down, but you could put warmth on that area, um, to hopefully let it, like, dissipate, but it doesn't necessarily mean, unless it's a long-standing abscess that's getting more painful, maybe larger, um, that you have to open it up in drainage, sometimes it can just, like, uh, dissipate on its own underneath. Cellulitis, um, I don't know if y'all are seeing a lot of this, um, it happens with anything, so a lot of these have not been xylosine specific, we're getting there, um, but cellulitis is a skin infection, um, it is common in the lower extremities, it is super painful, that skin is very tender, it's usually swollen, um, lower extremities, and you have that red color, um, it can lead to sepsis, and it does need IV antibiotics, um, so, you know, and it doesn't have to be anything drug-related that causes sepsis, you know, like, this person has what could be, this could have been the little, like, scrape on their, uh, shin that then got some kind of germ in it, and that ended up infecting that layer, and it's not usually, like, the epidermis, it's usually, like, the lower, uh, dermis that's infected, um, but it is really painful, um, it's usually pretty, like, shiny skin because your legs have swelled up. Other health-related things, so arterial means that blood is not getting down there, right, so our arteries bring blood down to our, our different parts of our body, so if you have arterial insufficiency, meaning the blood is not getting down to your hands or your feet, you're gonna see this like, you're not going to see this instantly, but you could see discoloration of your toes and your feet. You might have, if you had like a wound like this one over here, it might be really dry and not healing. Versus if you're having venous insufficiency where your veins are not bringing blood back to your heart, then what you're seeing is a lot of swelling. You're seeing something like this that might ooze a lot because there's just so much fluid that's pooling down in your legs because the veins are not taking it back. And then these are diabetic ulcers. Again, you know, if you have that decreased sensation that this could open up. So again, a good reason for people to keep an eye on their feet, a good reason for people to stay engaged in care for whatever's going on in their body. And definitely keeping an eye on our feet and our lower extremities to see what's going on and making sure that this is not a contributing factor. Like you might be doing, using drugs in all the right way. You don't have any kind of skin injuries from, from drug use. But maybe your drug use has allowed you to like, not address some of the things that were going on, um, other health issues going on that could just get perpetuated from not looking at it, not getting it treated, feeling like stigma, you know, of like not being engaged in your, uh, diabetic care. All right. Trach wounds or xylosine. Um, so xylosine wounds, I love this infographic. It was also brought to you by, uh, Jason, the wound care nurse. Um, but you'll see, so this one here on the left is, um, this is like one or two days after using. So this green is like the initial injection point. And these other ones are just where you're seeing, um, skin injuries pop up and you see this purpley stuff. Like, I feel like all of this could look like, it could look like a rash. It could look like a burn. It could look like a ringworm for some people, a bug bite for some people, spider bite. Um, but it's important to know, like, when we're talking about that preventative care, if people are using drugs, especially street drugs and like, they, we, they don't know what's in it. Maybe they're not getting their drugs tested. Maybe they are getting their drugs tested and they know that it's xylosine and fentanyl in there. Um, then making sure they're keeping an eye for any indication where they injected, or even around that area of just doing regular skin checks of, am I seeing anything that looks a little off that could be related to this? Um, that kind of looks like this is what I'm trying to say, because this is like four or five days after this. So that's how rapidly we're talking about things can progress. And, you know, even though this, none of these are open, the skin's not open yet. You see how quickly the skin did open, um, how, how quickly it opened and that you're getting this like black necrotic skin, which can also be called eschar. Um, and in multiple areas where this person did not use, um, so when, when this person first used and was starting to get these little spots, what they could have done is they could have took, um, you know, let's say like five different band-aids, put a little bit of ointment on it, covered it up just to keep an eye on it. Um, and that maybe would have prevented some of these big open up, uh, opening open spots that have eschar on them. Um, or they could have taken like one, one little dressing and just kind of done a loose layer on there to keep it protected. But that's kind of, that's what Fernando was talking about with the vasoconstriction is you have this, like in the research coming out. So there's vasoconstriction. And then if I was getting like a antibiotic transfusion in the hospital or something, and maybe, uh, the transfusion, the, like my catheter moved over a little bit and like the medicine started to leak into other tissues, it's called extravasation. And that's like a chemical injury to the skin, um, which in the hospital setting, we have to like treat ASAP because we know it can cause things where the skin becomes necrotic from the injury. Um, uh, the substance that's going was supposed to go through our veins and maybe, uh, you know, leaked over into other tissues. Um, yes, I'm looking. Oh yeah. Before that quick question, before you move on Lizzie, did you say that, um, or did you give a timeframe between where it could go from picture one to picture two? So this is one to two days and this is like five days after this one. And is that pretty typical? Yeah, it can be. Um, you know, but if people start to treat it, like it says at the very bottom, put petroleum or Neosporin or Band-Aid on it, um, to cover it up is that when it starts to open up, it's not going to instantly start to like crust over. And what we've seen too, is that when people have that, um, eschar on it or the, the dead skin is it could look like this for a while. Right. And people think like, Oh, it's stable. It's not doing anything, but it's basically having like a layer of cement on what could otherwise be healthy skin underneath that you're never getting a chance to heal. Um, so having that little Band-Aid with like ointment on it or whatever, it's going to keep it from having this crusty layer that you have to then work on removing before you address what's going on underneath. And if people are delaying removing, you know, taking just their time to add A and D ointment and moisture and covering it. Cause now the skin underneath is getting more and more compromised. The longer that this hangs out on the top layer of skin. Um, I don't know if we have a picture of it on this slide, but so something like this, where it's like even darker purple that wasn't here earlier. This, you know, these dark purple, if you work in the medical field, you know, that usually dark purple under unopened skin means a deep tissue injury. And so that's what you're seeing is like the beginnings of a deeper tissue injury. Oops, sorry. Um, and so like this one will probably open up or if it hadn't already. Um, but that's why we want to make sure that if we can, before this opens up, keep it moist and covered. So even if it does open up that it's not creating this crusty layer that could then keep people from getting, um, getting underneath this skin address, but then it could also like start to like, not necessarily tunnel, but grow. Right. Um, if that skin is injured and then it's just injuring neighboring skin, did that answer your question? It does. Thank you. Okay. Yeah. Um, so this is what I was saying with like early. So this is like where somebody injected and then these are just like other little spots that will turn into like spots that look like that. So you could even just cover this up with like maybe a large fabric band-aid or maybe, you know, just three band-aids or whatever works for them. Um, but it's, it's important to keep an eye on this. This is not this person. I will say that, that this is not the same, but this is just showing kind of like Fernando showed, um, these advanced, you know, but when I look at this as a nurse, this is pretty superficial, um, for right now. And mostly it's just, we have a really crusty area that needs some, some fixing, right? You just need to moisten that area. Um, I'm sure it is tight. Like if they're trying to move their arm, I'm sure it's pretty susceptible to getting hit. Um, it could be pretty itchy. So that's where that, like just basic, like, all right, we're not here to scrub off all the dead skin or anything, cleaning it gently, adding moisture to it. Um, and you know, let's say like these areas, they could have drainage. Um, and then, you know, you have a landscape where like this surrounding area could be like tender and red. It could be not tender or whatever. So what we've been trying to teach people that are working in the community is don't, don't think, well, like this area is draining. So I need to put an absorbent area here and this part's dry. And this part of this is just do those basic steps. And the wound is going to change, especially if you're addressing what you're trying to initially address, right. Which is getting all this dead, dried stuff off is the wound. Once those dead, dry skin, uh, areas start to like move or maybe get removed is you might have a whole new wound that's like is draining a lot, you know, has different colors in it. Um, and maybe it is, it is red, maybe it has some slough underneath. You don't know, but, um, I would not get too overwhelmed by what it looks like in here and just offer those basic services, um, and to see if you all can make a dent on it, um, and try to help people just remember, like, this is going to take time. It is important that you're not picking at it. It's important that maybe you're not using around it. Um, and you know, these are all easier things said than done, but just reminding them that like healing can happen. I think there's a picture of that, what I'm saying. Yeah. Okay. Wound care works. Um, so this is a good example, right? It kind of looks like the previous photo we looked at, but you can see like, um, you could see some areas that this is probably draining. This is crusty. Um, right. It's this person's hand. So, you know, they are moving it, which probably means that they're reopening spaces every time they try to use their fingers or wrist. Um, and then this is what you're seeing this like healing, even though it's not like the most beautiful hand in the world, right. It's way better than this. Um, and it's closed up is just that very basic. We're cleaning it. We are moistening it. We are trying to keep it covered and seeing what happens from there. And I will say though, you know, you could always remind people that like I was saying earlier, these healed skin is still not as durable as the skin that never had an injury on it like that. So making sure that they, you know, they're, they're still aware of like keeping that, um, trying to be protective of that skin. And if people, I will say, so maybe this person's like hand has healed up and then, but they're still having issues with swelling. What we've seen is you can buy on Amazon for people that like, you know, hands are just perpetually swollen are some of those like edema gloves, just like, you know, you have like head hose that you can put or, um, compression stockings or something. You can do compressions for hands. If people like have already healed their hands, or maybe they just want to get their hands down, um, from wherever they're at. Cause you know, those hands tend to swell and the massive, massive clubs Debridement, um, debridement, the one that I am talking about when I say basic wound care is just using, um, when like, so autolytic is that second one autolytic would be the body's enzymes used to liquefy dead tissue. Um, so autolytic would be, yeah, you put, you put some, uh, A and D ointment on it or meta honey or, uh, petroleum jelly or something or zero form. That is not what's breaking it down. Not those products, but you're giving it in an environment where the necrotic tissue can break down and the body can use the enzymes. Um, now enzymatic could be a prescribed like tube of goo that you could put on it. Um, sharp and surgical, that would be somebody who was trained. Um, and then there's other, you know, biological or mechanical, but the one that you'll be doing the most with just basic is autolytic, which means that you're not using anything too fancy and you're just allowing the body to do what it does and giving it a warm, moist environment. Good question. Are there, um, I know you said Manuka honey is very expensive and it's not really necessary. Are there places or situations where you really strongly prefer Manuka honey? Um, I don't strongly prefer it. Um, it is good. So it's, you know, some people already have a stash of it. Um, some people like if they are working with a clinic that is giving them their supplies and maybe they're just coming to you to receive extra help or like to show you what they ordered for them. Um, and that might be one of the things, but I mean, if people have it around and they know how to use it, they're using it as indicated. Um, there's nothing wrong with it. Like it has a few more like anti, uh, microbial properties. Um, but not enough where, uh, not, not, uh, not where you think you have to have that product or that a person feels like they have to have that product. Yeah. Makes sense. The world of wound care products are really cool. It's just so confusing and they're coming out with new ones all the time. Um, but yeah, sometimes people get like free supplies of those things. Um, so just again, letting people know if you don't keeping it for an extended amount of time, or if it's not something you're always supplying, um, that you have a infographic kind of like the slide from earlier where you can say like, yeah, meta honey is one of many things that we could use to get this removed. Yeah. And for whatever reason, if someone's like the meta honey was causing me irritation or maybe attracting flies or ants, I don't know. You could say, oh, we can try something else. Yeah. I don't know how much you all need me to focus on this, uh, slide. You're pretty familiar with safer injection. Okay. I figured, um, what a grainy photo. Uh, but you know, you can see that there are a few things going on here, right? So that the small blue arrow is pointing to like slough. Um, you see some like pink and red underneath that means that, Hey, there's some like viable tissue underneath. Um, and then when it says like, what treatment would you provide for this? You guys can say it. Um, but yeah, you would just want to make sure that you're not pulling or ripping off anything. You're just doing exactly what we did earlier, which is trying to clean it off if you can, um, covering it. And then eventually that will come off. This can be pretty sticky, uh, but just with enough, like patience that usually comes off. Um, I mean, it comes off in the, in the, at that episode during that visit or you mean later? Slowly, slowly. Yeah. Um, cause that seems like a pretty big, like chunk. Um, so which means that it could be like pretty stuck to the area. Um, but just, it doesn't necessarily mean that it's like super infected or anything like that. Um, it just needs time to come off. Um, that's the epithelial. We can see the like pink and the red tissue, which looks good. Um, and just keeping it covered and, and, you know, a small layer of moisture to make sure it's almost healing them. I don't know how many slides I have and what my time is. Oh, here we go. All right. Any questions? I just want to clarify. Um, you said that, um, one of the things is your, your advice for somebody who's still actively using is don't use at the same site. So I take it that some of these people who are healing over six months a year, they are actively consuming. Yeah. So, you know, when I said the six months to a year, that was just like, uh, an example of if somebody was like, I had a pretty advanced wound and wanted to like address it. Um, you know, if people are using, and I think that in Fernando's slides, it said it is like most people are having issues, uh, when they are regularly using xylosine, um, where they are having issues of areas reopening, maybe ones that have previously healed depending on where they're using, um, or, uh, or they just have new spots because they might be using a new one. So it's just important to remember is the xylosine, especially depending on what concentration is in the drug supply that you're using could be still causing injury. Um, and that's just going to be something they have to address if they're still using drugs that have xylosine in them, but staying on top of it. Right. So if we're able to like address those areas and just try to keep the wound burden a little bit under control, uh, for appearance sake, for pain sake, to hopefully avoid having to like have a larger interventions, um, will hopefully put them in a better place. But yeah, the reality is, is regular chronic xylosine use can cause these skin injuries, especially with injection. Um, and just making sure people know what those, those initial, uh, injuries look like, right. Those tiny little red spots. And I can't, I also have, do not have photos of people with darker skin. It just seems to be like light skin people is the only photos we have of these early, uh, xylosine injuries. So, um, I wish that I had some to be able to share, to say like, this is what it could look like in darker skin. I just don't. Um, but that preventative part or that just, you know, staying on top of regular skin checks goes a pretty long way. Thank you. I had another question for you, Lizzie. Um, when you said that the healed skin is not as strong as like your baseline skin, is that like forever or It is for a lot longer than we think. Um, I forget what the actual time is. I actually like learned that from, uh, a wound care nurse practitioner out of Philly, uh, we were presenting together and she said, and I was like, Oh my God, I didn't even think about that. Um, but yeah, especially if it's, uh, not just like the epidermis layer or the dermis layer that had been injured, but also previously under structures of just like how much rehabilitation and, and, and work in your body is doing to like bring the vasculature, the nerve endings, you know, building that, um, skin matrix so that it's as strong as the neighboring skin. Um, but just reminding people that like, that if they are using in that area again, that it has a likely higher, uh, a likely, a higher likelihood of breaking down sooner just because it doesn't have the same strength as skin and from previous places. Right. And, and then with the, the one picture that you showed us, that was like four pictures and it was a progression of the person's hand. When is it appropriate to no longer need to be like covering that? I would say until it's not open anymore, where it's the see, everything's closed up. Um, cause she still had like some crustiness on like that last photo, um, of just like where the skin had come together. So, you know, I think that maybe she doesn't need to like apply a bunch of ointment to it or whatever, but if somebody is like, just, I, they know themselves well enough to know that they're going to like, start to pick at it. Um, you could say like, just for like deterrent reasons, like you could put a tiny little layer of like Curlix on it or something like that. But, um, yeah, when it's closed up, it should be just fine. And I definitely think there needs to be more drug testing. It's also, it's been mind boggling to work with the hospitals and wound care clinics, and they just have no clue about xylosine about the drug supplies or anything like that. And, you know, that has been really important work to let them know that like, you need to know what's going on in your community and you need to know who's working with these people on a regular basis because they're able to give you a lot more guidance. And obviously if you talk to the people that are also experiencing the thing and use the drugs every day, they can also give you a lot of guidance. But yeah, the whole we don't know exactly what people are using on a regular basis is scary. Are you, are you all not doing a whole lot of testing. Um, so we, so I work at the Maryland Department of Health Center for Harm Reduction Services and I also work doing community psychiatry, but I'm through the Maryland Department of Health, our grantees, which are local health departments and different community based organizations across the state. We supply them with all their fentanyl and xylosine test strips. Some of the places have their own research projects that are doing mass spectrometry. But then we also partnered with the National Institute of Standards and Technology, which is a federal lab NIST. And so, if people want to participate it we call it the RAD program which is the Rapid Analysis of Drugs. It is not real time results which really stinks, but it has given us some indication of like what people are using. But it's where people either bring in something to get swabbed or their old syringes or something. And when they, the person at the harm reduction organization or local health department receives it, they say okay what did you buy, what did they call it, what did you think it was, and then when they get the results are getting it broken down into like all the components, which it's voluntary so it's not like we're doing it, it's only when people will want to have their stuff tested, or their staff able to test it. And results usually come back within like two to three weeks, so that's not great for anybody who's like wanting to know that information before they use. But it's something, something, but it's definitely not the solution for anything. Have you worked with NIST at all? Yeah, actually that's the lab that we're partnering with. And they've been, NIST has been great. They really have. The best part is that it's free. The best part is free. And I will say it's not NIST who's causing these delays, it's just the normal USPS, so. Which I love the postal service so I have no shade on that. I know they're doing their best. Fernando, I actually have a question for you. Are you finding that there's not a huge place for test strips anymore with your, or maybe there hasn't been for a while with your community or is there still? They're not very popular, right, because they're inconvenient. I think it would be important to integrate that kind of technology into things that are more intrinsic to the process of consumption. So like if a cooker or the syringes that are distributed or the cottons that are distributed contain testing technology within them so that people don't have to do something extraneous to the process of using to test their stuff. I think this kind of testing would be clearly used more frequently, right? Right now they're seen as kind of an inconvenience. People are often going through withdrawal when they finally get to obtain their opioids, right? And that extra step is like another minute of torture, right, for a person going through dope sickness. So there's a lot of barriers in addition to all the questions of access that are standing between, you know, FTS and regular use, right, test strips and regular use. But, you know, I think that test strips are still important for parts of the supply that are more variable and less predictable, right? So people who use pills, I think, find more use for the strips and people who use opioids will generally know that they're using fentanyl and psilocybin. And then, you know, in parts of the country where the stimulant supply is more variable and where there is sometimes a little bit of fentanyl or psilocybin, I think that would be important for them to use it. But I would favor, yeah, a development of the test strip technology so that it's incorporated into, you know, into the use process instead of being something extra. And then, you know, I guess, you know, following up on what Lizzie is saying, I think we need a speeding up of technological development in this field, right? If rich people were the ones suffering from wounds, we would have gone from the mass spectrometer to, you know, the MacBook Air version of the drug testing technology in months. The reason why that hasn't happened, the reason why the mass spectrometer still takes up an entire room, just like computers in the 1960s did, is because it's poor people suffering from these problems. So. Yeah, I fully agree. So I just put in the chat that document I was talking about. But one of the things that we've been trying to give our patients or the people experiencing these issues a leg up, as well as, you know, really trying to make sure that the medical world can no longer be like, well, we just don't know. And therefore, we're not going to do it, is we have kind of like a face sheet, almost like if you call EMS and then they are taking them to the hospital or whatever, is like, we'll have like what we have done for the person in regards to their wound and what they've done and how long we've worked with them and our contact information if they need it. But we also on the backside of that have the latest like, hey, we test in Maryland for what people use and we are seeing that there's this thing called xylosine and then we're giving people facts, but then we're saying, you know, if you treat somebody, if somebody is suspected of having opioid withdrawal and you've treated the opioid withdrawal and they're still having these symptoms, then it could be related to this. And here's the guidance on xylosine withdrawal protocol, or sorry, like guidance, because it's not a standard protocol yet. But really just trying to get out there to these medical places and more traditional healthcare is like, we have more information and like we need to give it to you, you need to utilize it and like here are the best practices, which are in these documents. But like, if people are engaging with care, like not so they have, they don't have to be the ones educating the healthcare providers, but that we can, while advocating that they have been attempting to care for themselves out in the community and now it's the point in time where they need to seek a higher level of care. Nancy. Could I ask? Yes. So back to Fernando's recent urging us to really look at innovation. You know, it's been, I'm a historian and so I look a lot at innovation in this field, particularly in harm reduction. And you could tell a whole history, really, of just the technologies that were developed in order to talk about wounds, even in the 19th century for morphine injection, when that first began to be a thing. There were certain kinds of technologies that were created in order to educate physicians about abscesses and hair, et cetera. So I have a harm reduction design studio this fall, and it's the first time I've ever taught in a design studio as a historian of drugs and drug policy and harm reduction. And it's going to focus on design problems that are kind of solvable problems. And it occurred to me that I should ask you guys what problems, because exactly what you just, you know, said, you know, there were when physicians started to take mass spectrometers out into the field to outdoor rock concerts and things like that and start to look at, you know, how do we do harm reduction. You know, there were when physicians started to take mass spectrometers out into the field to outdoor rock concerts and things like that and start to test drugs, right, back in the 70s. There was a lot of innovation, right? There was like a burst of innovation about this. So what should we be looking for? What would, you know, if we're going to integrate test strips into use, into consumption, like, you know, where would you look? I mean, you've been interviewing people. You've been talking to people for a long time. You know, give me some design problems, some needs that I can give these kids to chew on. They're engineers also. Many of them are not just designers, but they're also engineers. And so they're really interested in things like, you know, thermal transfer and, you know, things that I don't know anything about, but they will know things about. So any ideas for innovations that you want to see in the harm reduction field? And you can even think of these over the next couple of months and email me. I'm Campbell at RPI.edu, because I'm really thinking about this right now, the kinds of things that we could use. And wound care struck me as one. That's why I came today, because I thought, you know, this is a, it's a, it's a, you know, field that's kind of ripe for educating people how to take care of themselves and each other. I'd also be really interested in hearing Lizzie's ideas. But first of all, I wanted to say, like, I'd love to be a fly on the wall in that class. I'd love to audit it. It sounds fantastic. I'm going to invite you. This is really important. And, well, you know, in terms of just like my very rough ideas, not very sophisticated ideas. I mean, one is kind of what I've already mentioned of incorporating the testing technology into, for example, the cooker, which probably is the most natural place for that to go, organic place for that kind of technology to go. Like, you know, the cooker could turn a certain color if there's fentanyl or xylosine in it. And maybe this is not possible, but, you know, maybe it could also be, to some extent, a quantitative testing technology where it's not just the presence of one substance, regardless of its concentration, that makes the cooker turn a certain color, right? It can only be, it will only turn a certain color if it's over 1% or 2% fentanyl or something like that. You know, that would have to be thought out, but, you know, so that it would have, so that the information gathered from the testing is a little more robust, a little more informative than what we have currently, right? And the other thing is about, like, improving the limitations of the FTIR technology, which, you know, like, I'm sure you know that harm reductionists call it the baby spec because it's kind of the baby, you know, the baby mass spectrometer that you can carry around. It's $50,000 instead of $600,000, so it's the technology that's a little more accessible to community-based organizations, right? But the baby spec has the very significant limitation that it won't detect things under 5% if they're present in concentrations under 5%. And so you end up missing a lot of very crucial information, right? If you have fentanyl present in a substance at concentrations of 4% or 3%, that's really important information that the baby spec currently isn't capable of detecting. So cheapening that technology and making it more capable, eliminating those limitations would be the way to go, I think. I'm not an engineer, I have absolutely no idea why baby specs are unable to detect concentrations under 5%, but those would be my suggestions. Great ideas, thank you. I was a little worried when you said that people weren't cooking anymore, they're not using heat, because I have been thinking about this, like, wouldn't it be nice to have a detection, yeah, the quantitative detection, right? So it's not just a yes or no, especially when we're pretty sure it's present. But we just, you know, really want to know what the percentage, what the dilution is, and what else is there? Because, you know, dilutants can also have problematic effects, which, yeah. So, Lizzie, ideas. Thank you for those. I think that's, yeah, it's really interesting. Even when we think about treatment technologies, there's just been, you know, I mean, I wrote a lot about naloxone, there's just been so little innovation in this field. It really is a neglected area. And you gave me lots of ideas, both of you, about knowledge problems and research problems and things like, I mean, I didn't know that xylosine withdrawal wasn't better elucidated than it is. Yeah. I will share, I just tried to see if it was in a shareable form, and it is, but it'll have to be attached in the email, which is that study I was trying to tell, that I was saying that Hopkins did on the wound care continuum. Is it a perfect study? No. But I think that it helps, like, kind of address what we were seeing on multiple levels. And kind of like I was saying earlier with the documentation piece, I think the frustrating thing, when we've been talking about, like, our leadership, our, like, Governor's Administration and, like, the Secretary of Health or whatever, is they're like, you know, like, well, we're not going to do this. We're not seeing wounds as an issue in the hospitals. You know, like, that's the only place where they can gather data or they can, like, show that, okay, X, Y, and Z person came for this, like, soft tissue infection, and this is how it was treated, and this is their length of stay or whatever. So I've been just trying to legitimize what anybody is doing in the community around these and how to document it without it being more data that people have to share and collect. Like you said, how can we just do a better job of educating people where they're able to do self-care? So really just trying to, like, simplify the messaging. I have an idea of, like, trying to make it easier for organizations to track, like, how people's skin issues are progressing or healing. That they would be able to, like, have their own database of, like, the images because we don't need it at the state level. We just want to make sure that people have funding for whatever care they need to provide for their people. But I know that we have these organizations and places that are providing care, whether it's hands-on, whether it's the handing out of supplies and the giving of information, but there just isn't a real understanding of, like, on this continuum, are these things resolving? Are people having other, like, touch points? And, I mean, this is such a huge, vague question of just, like, how to have a better understanding of what people are experiencing around these skin issues and, like, what is actually healing them, right? So we could have all these recommendations, but those are the people that we're seeing, and we're only seeing a certain amount for whatever reason, you know? Even familiar faces that I know have wounds, it's, like, they'll be, like, bye, you know, and I'm, like, all right. I can't make him stop or do anything. So it's a real, it's a huge mystery, it really is, of, like, what exactly people are experiencing and just hoping that funding stays available for people to, like, continue to do the work and get, dig a little deeper into, like, how we can be the most helpful and not just, like, know the prevalence of stuff, but, like, make sure that people, you know, can advocate for themselves and know what to advocate for. And that's been the most frustrating thing is, like, I feel like nothing I'm talking about is that innovative. It's just, like, this basic knowledge gap, which is, I think people actually have this knowledge. It's just, like, reassuring people, just, like, reassuring medical people that, like, you can put your hands on people and not get sued, you know? Like, that's what you're actually, like, trained to do. But I don't know. The world is scary. I don't know if that was. I might have questions, but I do have one question for you, which is when bacteria is present in a wound, can you always see it or is it present before you can see it? And so you might be able to detect it without it being visible to the eye. You said bacteria? Yeah. Totally. I mean, you have bacteria everywhere, so you're going to have bacteria in the wound. You're just, like, when it becomes infected, which is one of those slides, right, is where you're seeing, like, it's red or swollen and tender or might be, like, producing, like, because that pus or that slough is just, like, dead immune system, right? Because it's just, like, your immune system showed up to kill out the bad bacteria, and then it's hanging around. But if we have, like, gooey things hanging around, then that's going to attract more bacteria to stick onto it that might create a whole other infection where we're staying in that inflammatory phase. So you're not going to necessarily see, like, oh, this is good bacteria or bad bacteria. There's always going to be bacteria on there. Just, like, is it causing an infection, a local infection, or, heaven forbid, a systemic or a septic infection? But bacteria, it's not all bad. So it's just making sure that it, like, looks like it's healing, right? It's less red and tender. It's, sorry, like, you know what I mean? Not, like, we were looking at images of the wound that had blood flow, right? So they were pink and red. That was good. I'm talking about, like, if I had an abscess, right, it would be, like, pink and red and hot to the touch. It would be painful and all that kind of stuff. So just making sure that are we moving in a direction where the area is becoming back to its normal functioning area, which I can also share. I'll just, I'll send it to Chris, but just, like, a couple of things that I share statewide that, like, you can happily use or not use if it applies to you. Great. Thank you. I'll forward those. Yeah. Well, we are, I want to make sure that we let our wonderful trainers have the rest of this beautiful night, beautiful year. I hope it is there, too. Any other things before we close for today, Mandy and Nancy? Just thank you. Yeah, thank you all. Thanks so much, indeed. Really informative and learned a lot. And thanks, Mandy and Nancy, for being here as well. Maybe, hopefully, we will see you again on, well, I'll see you again on the 11th for our Modules 3 and 4. And yes, so thanks very much and look forward, maybe, seeing you in the design class. Yeah, absolutely. It was nice meeting you all. Thanks for having us. Thank you. Thanks for having us. And I'll be in touch with our co-host soon. Bye, Fernando. Bye, Lizzie. Good to see you. Bye.

emerging drugs

fentanyl

silazine

methamphetamine

Philadelphia

drug supply chain

trank burns

withdrawal symptoms

health risks

harm reduction strategies

Xylosine

fatal overdoses

comprehensive drug checking programs

wound care practices

skin injury management