It is well known that people who use drugs (PWUD) leave the hospital via patient directed discharge (“PDD”; also known as against medical advice “AMA”) more often than people who do not use drugs. The introduction of xylazine – a veterinary tranquilizer – into the United States (US) synthetic opioid supply has only exacerbated this situation. The following paper reviews the literature on xylazine, hospitalization with opioid use disorder (OUD), and how xylazine has changed the experience of hospitalization with OUD. The research revealed that xylazine causes respiratory depression, sedation, and the formation of necrotic wounds. There is currently no treatment for xylazine dependence, overdose, or withdrawal. The literature further revealed that inadequate management of withdrawal and pain, along with stigma from health professionals, are major reasons why PWUD leave the hospital PDD before completing treatment. The difficulty the health system faces with the management of xylazine withdrawal and the necrotic wounds it produces only exacerbates this problem and necessitates increased attention to this topic. Using opioid agonists to treat withdrawal decreases rates of PDD for PWUD in the hospital. This paper will argue that the treatment of PWUD in the hospital with opioid agonists in order to address withdrawal and pain is ethically necessary; and that the introduction of xylazine into the synthetic opioid supply in the US only further necessitates the collective adoption of this viewpoint. / Urban Bioethics