"It always needs a higher level of care than what I can provide": Practical, ethical, and administrative tensions arising from the integration of wound care services into syringe service programs in Maryland.

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The emergence of xylazine into the U.S. drug supply has increased demand for wound care services among people who inject drugs (PWID). Traditional health care settings have historically been ill-equipped to accommodate the complex needs of PWID and syringe service programs (SSPs) have created wound care services to fill the gap. In doing so, many SSPs are extending the scope of their services beyond health promotion into a quasi-medical space that is largely unregulated. We conducted 10 qualitative interviews with staff employed by eight SSP programs across six counties in the state of Maryland to explore how they have navigated shifting demand for more intensive wound care services. Contested boundaries in training of non-medical staff, lack of clarity in SSP-based providers' scope of practice, and conflicts in operational norms and standards between harm reduction and medical services are significant sources of tension that impact delivery of wound care services in SSP settings. In taking on responsibility to provide wound care services to PWID, SSPs take on significant administrative, practical, and ethical burden that increase vulnerability to medicolegal liability. There is a significant unmet need for increased resources, administrative support, and mentorship to guide the integration of medicalized wound care into SSP programs. Additionally, efforts to expand access to community-based wound care services for PWID should not replace efforts to promote timely access to services in more traditional healthcare settings.