Increased injection drug use has led to a spike in cases of the life-threatening heart condition endocarditis, with cases rapidly accelerating since the onset of Covid-19.
The increased case count is one of the lesser-known side effects of the deadly addiction epidemic. But patients with endocarditis, an inflammation of the heart lining caused by infection, require complex, thoughtful care — care that the U.S. health system is ill-equipped to provide.
With drug deaths hovering at an all-time high and endocarditis cases among drug users up nearly tenfold in the last decade, physicians, researchers, and health officials have begun to confront the problem with more urgency. In particular, doctors are coming to terms with a basic reality: Their hospitals often have few protocols for treating endocarditis patients who use opioids and the withdrawal they’ll likely experience upon admission.
“We’re taking steps in the right direction, but we need to do much more,” said Daniel DeSimone, an infectious diseases specialist at the Mayo Clinic in Minnesota. “We need to do better with regard to managing opioid withdrawal in the hospital.”
In areas with high rates of injection drug use, infectious disease outbreaks are nothing new. In the past decade alone, the U.S. has seen outbreaks of HIV and hepatitis C associated with increased opioid use.
Between 2011 and 2022, the rate of new endocarditis among patients with opioid use disorder increased dramatically, according to new research published by the National Institute on Drug Abuse and scientists at Case Western Reserve University. Among drug users, most endocarditis infections stem from the use of non-sterile syringes, allowing bacteria to enter the bloodstream and, eventually, the heart.
Among people with opioid use disorder, the rate of endocarditis jumped from 4 per million per day to 30 per million per day. The sharpest increase occurred between 2021 and 2022 — a spike that the study’s authors attribute to the Covid-19 pandemic.
Care for endocarditis, which is not always caused by drug use, typically consists of a course of antibiotics delivered by IV drip. Some patients receive what’s known as a PICC line, a larger form of IV used when they’ll require medication for several weeks. Many cases require surgery to repair or replace damaged heart valves.
Such care is complicated to begin with. But for patients with addiction, each of those steps adds a new layer of complexity — in particular, lengthy hospital stays and ensuing withdrawal for patients accustomed to regular opioid use.
“You have someone that has very strong physical dependence to opioids, they go into the hospital, and they go into withdrawal, and that withdrawal can be very, very severe,” Nora Volkow, NIDA’s director and the co-author of the recent study, said in an interview. “They may leave the hospital against medical advice, because they’re not being treated for the severity of the withdrawal symptoms.”
Even when patients’ withdrawal is treated, Volkow said, patients “stay throughout the whole hospitalization as needed — and then they get released with no linkage to treatment or care.”
Keeping patients in the hospital, however, is only half the battle. In cases where patients remain in treatment, many still don’t receive the resources they need, or the expertise their care requires.
Even once patients’ infection and heart condition has been addressed, discharging them from the hospital can present unique challenges. Many of those who inject drugs are also experiencing dangerous or unpredictable housing situations, and those whose addictions remain untreated often quickly return to use.
Many of those patients soon wind up readmitted to the hospital for repeat infections. In recent years, such cases have engendered frustration from hospitals and additional stigma among health providers — even leading to public debates about whether patients with multiple endocarditis cases are worthy of additional care.
As a result, some doctors seek long-term care facilities where their patients can recuperate in a more stable environment. Even in those cases, however, the U.S. health infrastructure poses major obstacles.
“I can’t tell you the number of times I’ve had skilled nursing facilities say they will not accept a patient with addiction, because of challenges getting them methadone or getting them buprenorphine, or other reasons that seem to be code for stigma,” said Ashish Thakrar, an addiction physician and postdoctoral fellow at the University of Pennsylvania’s National Clinician Scholars Program.
The spike in cases, and growing recognition that the U.S. health system is ill-equipped to treat complex patients experiencing addiction, has spurred calls for improving treatment standards.
The American Heart Association last year issued new recommendations for endocarditis care that revolve around treating the patient’s underlying addiction. The AHA’s multidisciplinary approach, in an ideal scenario, would include input from doctors in at least four fields: cardiology, cardiac surgery, infectious disease, and addiction medicine or addiction psychiatry.
The Department of Justice has weighed in as well, issuing guidance and announcing a number of settlements and new lawsuits aimed at forcing health care facilities to admit patients who’ve been prescribed addiction medications like methadone or buprenorphine.
While some experts welcome the new guidance, they concede that in some cases it’s impossible to live up to.
“Most hospitals don’t have addiction consult services,” Thakrar said. “Most hospitals are not going to have access to addiction expertise, and in part that’s because hospitals haven’t paid for it. It hasn’t been a priority. … A lot of hospitals don’t have specialty services, so a lot of providers and cardiologists might be left without anyone to call.”
The resulting void forces other doctors — in this case, cardiologists or infectious disease specialists — to treat their patients’ addiction, which they’re sometimes ill-equipped to do.
DeSimone, the infectious disease specialist who was the lead author for the AHA’s new recommendations, acknowledged those doctors may be uncomfortable providing addiction medications, like writing a prescription for buprenorphine or connecting their patients with a methadone clinic.
The failure to provide comprehensive care is a big missed opportunity, Volkow said, because patients hospitalized with endocarditis are a “captive audience” for addiction care. A hospital, she argued, provides patients with medications, food, shelter, and safety — in other words, an ideal setting to begin addiction treatment.
Moreover, patients whose addictions remain untreated leave the hospital at even higher risk.
The condition “may require heart valve repair or complete replacement,” DeSimone said. “That typically requires the use of prosthetic material — and particularly for patients who inject drugs, that hardware now predisposes you to getting infected again.”
The increase in infective endocarditis has taken place amid a broader debate about the impact of “harm-reduction” strategies — services including syringe exchange, which data shows as highly effective at preventing infectious disease transmission.
In recent years, however, local governments in Indiana and West Virginia have moved to limit or outright close syringe exchange services. Even left-leaning leaders, like President Biden or California Gov. Gavin Newsom, have resisted the opening of proposed supervised injection sites that would provide syringe services alongside medical supervision for people using drugs.
Last year, conservative media caused an uproar by falsely reporting that the Biden administration planned to use federal money to distribute sterile pipes used to consume methamphetamine or fentanyl, among other drugs. In response, the White House issued a formal denial — and lawmakers from both parties introduced legislation meant not only to ban the use of federal funds for sterile pipes, but also to prevent government money from being spent, for the first time, on clean syringes.
While the $30 million allocation for harm-reduction services last year was unprecedented, critics say it wasn’t enough. And when communities lack access to services like syringe exchange, Volkow said, the results are easy to predict.
“During the Covid pandemic, many of the community services that exist to support people that take drugs — including, for example, syringe exchange programs — were closed,” Volkow said.
She added: “You can look at it throughout the whole world: Areas closing their syringe exchange programs are followed by outbreaks for HIV, and we’re seeing the same thing with hepatitis C. We can very much predict it is also associated with infectious endocarditis.”
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