May 10, 2018

Is a heart 'ever not worth fixing?' Amid the opioid epidemic, some surgeons are confronting the question.

Daily Briefing

    Hospitals are seeing a rise in cases of patients who present multiple times with a heart valve infection called endocarditis, often due to continued misuse of opioids or meth—a situation that presents doctors with the "ethically fraught question" of whether a heart is "ever not worth fixing," Abby Goodnough reports for the New York Times

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    About endocarditis

    Endocarditis is a life-threatening infection often contracted when bacteria enter the bloodstream during injected drug use. According to CDC, the number of endocarditis cases in the United States has increased "in association with the current opioid [misuse] epidemic."

    To treat endocarditis, patients usually take intravenous (IV) antibiotics for up to six weeks. According to the Times, physicians often keep patients in the hospital for the duration of the treatment out of concern that patients might misuse IV lines for illicit drugs. 

    In addition to antibiotic treatment, endocarditis patients often require complex open-heart surgery to replace or repair damaged heart valves. For instance, Jerika Whitefield, who contracted the infection after injecting meth in 2016, underwent a three-hour operation to repair a mitral valve—a procedure that involved opening her breastbone, connecting her to a bypass machine, and having her heart stopped while doctors repaired the valve. According to Thomas Pollard, a cardiothoracic surgeon and co-operator of a practice owned by Covenant Health, such a procedure can cost more than $150,000.

    And many IV drug users who contract endocarditis continue to struggle with drug misuse or other health risks after the procedure, the Times reports. A 2016 study involving two Boston hospitals found 41% of endocarditis patients who were not IV drug users survived for a decade without complications or reinfection, compared with just 7% of endocarditis patients with endocarditis who were IV drug users.

    Physicians face tough ethical question

    For endocarditis patients who have a history of injection drug use, physicians say they must consider ethical questions about whether to proceed with surgical intervention, given the patient population's risk of reinfection and the costs associated with treatment, Goodnough writes.

    So far, guidance from professional groups, such as the Association for Thoracic Surgery and the American College of Cardiology, about when to operate has been vague, according to the Times. Carlo Martinez, a cardiothoracic surgeon who co-operates the Covenant practice with Pollard, said, right now, "it's just a lot of anecdote—surgeons talking to each other, trying to determine when we should and when we shouldn't" operate.

    Pollard said his practice will nearly always operate on a person experiencing his or her first case of endocarditis from injecting drugs. However, when a person experiences the infection a second time and the damage to his or her heart valves becomes more extensive and complicated to fix, it is more difficult to decide whether to treat the patient, Pollard said. The decision is particularly challenging if the patient "continue[s] using drugs while in the hospital," a situation Pollard likened to "trying to do a liver transplant on someone who's drinking a fifth of vodka on the stretcher."

    Pollard added that many endocarditis patients lack access to substance use disorder treatment. Meanwhile, drug use raises their risk of reinfection.

    Mark Browne, Covenant's SVP and CMO, said, "Each patient is evaluated individually and decisions regarding the appropriate course of care are determined by [his or her] attending physician."

    Physician lobbies hospital systems for patients to receive misuse treatment

    In 2016, Pollard established a task force—including representatives from Covenant, the University of Tennessee Medical Center (UTMC), and Tennova Healthcare, as well as from community groups and two drug centers—on the topic. The task force recently backed a pilot program, proposed by Pollard, that would provide endocarditis patients who have misused drugs with substance use disorder treatment as part of their care plan. "This should be part of the treatment, just like antibiotics are," Pollard said. 

    Under the proposed pilot, participating hospitals in the area would send a "handful" of endocarditis patients to a substance use disorder treatment center, called Cornerstone of Recovery, as soon as they were discharged from the hospital. The treatment center would offer patients several months of inpatient treatment and up to a year's worth of Vivitrol, a shot designed to block cravings and help prevent people from relapsing. Vivitrol costs $1,000 a shot per month, the Times reports.

    Under the proposal, patients who receive treatment would have to sign an agreement stating that they would not be eligible for future heart surgery if they continue to misuse drugs. Overall, the services would cost approximately $55,000 per patient—but Pollard said the cost could be at least partly covered by public and private funding donations, should the program be expanded.

    With backing from the task force, Pollard has asked the health systems represented in the task force to consider joining the pilot program. He has pitched the program as a way not only to improve treatment for endocarditis patients who misuse drugs, but also as a way for physicians to garner additional justification for not treating endocarditis patients who declined the treatment offer. In the long run, the proposal could generate savings for hospitals, he said. 

    Limited progress

    But progress has been limited, the Times reports. While Pollard said he was close to convincing Covenant to helm the pilot, Browne in a statement said "due to the high cost of residential and outpatient treatment, no commitments have been made to proceed."

    Jerry Epps, CMO at UTMC, called the proposal "a big ask." Epps added, "The hospitals are already paying a huge part of the financial burden for this patient population." Epps said his hospital has taken steps to deter illicit drug use among inpatients already, such as requiring that patients who are admitted for infections related to IV drug use give up their phones and their privilege to have guests for the first week of their hospital stay. Browne said Covenant adopted a similar policy.

    Pollard, who is moving with his family to a new practice in San Antonio, said, "In some ways, I'm disappointed" the proposal has not seen significant movement. He said, "But it's been forward progress, and I do think something will happen, probably this year. … If we can just get the pilot study done, people will begin to notice" (Goodnough, New York Times, 4/29).

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