LEXINGTON, Ky. (Sept. 13, 2016) — Individuals who inject drugs are at risk of endocarditis, a bacterial infection that enters the bloodstream and clusters on the valves of the heart. The infection requires prolonged antibiotic treatment and, in some cases, surgery. Without intervention, the infection can be fatal.
In the past 10 years, the number of patients presenting to U.S. hospitals with endocarditis has doubled with the proliferation of prescription opioid and heroin addiction. Endocarditis requires a team of providers, including doctors trained in infectious disease, cardiology and cardiothoracic surgery, working together to manage the condition through antibiotic therapies and heart valve repair or replacement procedures. Patients with opioid use disorder receive evidence-based treatment to repair their hearts. But the underlying cause of endocarditis —opioid addiction — lacks evidence-based treatment and intervention during hospitalization.
Two health care providers at the University of Kentucky called attention to the need to integrate treatment of substance use disorders during acute care hospitalizations in a recent article published in the New England Journal of Medicine. In the article, Dr. Laura Fanucchi, a UK HealthCare internist and faculty member in the Center for Health Services Research, and Dr. Michelle Lofwall, an addiction medicine specialist and psychiatrist at the Center on Drug and Alcohol Research, delineated the course of treatment for an addicted patient admitted to the hospital for endocarditis. Without evidence-based treatment for addiction, this patient returned to injection drug use after discharge. He suffered a recurrence of endocarditis, required subsequent heart valve replacement surgery and died from complications after another prolonged hospitalization.
Although tragic, this patient’s case illustrates a common outcome for endocarditis patients with an untreated opioid addiction. Patients who continue to participate in injection drug use after their initial surgery are at risk of a repeat infection and life-threatening complications. Addicted patients who receive a heart valve replacement are 10 times more likely to die or require reoperation between 90 and 180 days after the initial surgery than other patients. These cases also overburden health care providers, who might perceive the valve replacement procedures as futile, and cost the health care system billions for inpatient care.
“Currently, we are not routinely assessing the severity or treatment needs of the underlying opioid use disorders, initiating evidence-based treatments, and supporting risk reduction,” Fanucchi said. “Though opioid use disorder is a complex medical illness amenable to treatment, stigma and conflict unfortunately continue to influence care, frustrate providers and marginalize patients.”
The authors argued hospitalization for conditions such as endocarditis present medical teams with opportunities to introduce medication-assisted therapies (MAT) for opioid use disorder such as buprenorphine, methadone, and naltrexone. Fanucchi and Lofwall implored medical providers to integrate substance use disorder assessments, MAT, and harm-reduction measures into the treatment process.
The authors also demonstrated that the current system for advising opioid users during acute care has failed to produce positive outcomes. Patients with opioid use disorders and endocarditis are often hospitalized for weeks to administer antibiotic therapies. Forced withdrawal from opioids during hospitalization creates tension between the patients and health care providers and sometimes leads to early discharge. Health care providers often interpret requests for opioid medications during hospitalization as drug-seeking behaviors. Patients are discharged from the hospital lacking sufficient treatment for their addiction, often returning to injection opioid use, which can lead to a recurrence of endocarditis.
Fanucchi and Lofwall aim to develop an evidence-based mechanism for integrating MAT as a simultaneous treatment during hospitalization for acute problems. The researchers are conducting a study to assess the needs of opioid-addicted patients who are admitted to UK HealthCare with endocarditis. They plan to use the results to inform the medical community of how to address opioid addiction in the most beneficial manner for patients, providers and the health care system at large.
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