To treat severe injection-related infections in people with substance use disorder, collaborate

Here’s a too-common infectious diseases consultation:

A 30-year-old man comes to the ER with two weeks of fevers, chills, and back pain, plus increasingly difficult breathing for the past two days. He has injected opioids for the past five years. He has abscesses in the left arm, tenderness in the low spine, and a new heart murmur. His doctors obtain blood cultures, start IV vancomycin, and bring him into the hospital. After a few hours, his blood cultures grow Staphylococcus aureus. An echocardiogram shows infective endocarditis of the mitral valve with destruction of the anterior leaflet and severe mitral regurgitation, a CT of the chest reveals multiple septic pulmonary emboli, and an MRI of the back shows lumbar vertebral osteomyelitis/discitis and psoas abscesses.
What to do?

Perhaps your first instinct is to focus solely on the staphylococci invading his body – to make treating him a matter of advising your hospitalist colleagues which antibiotics to give and for how long, of knowing where to ask the surgeons and interventional radiologists to put their scalpels and needles. This approach is incomplete, but unfortunately, the medical literature tells us it is also typical – patients often receive high-quality care for the treatment of their bloodstream infections while receiving little to no attention or care for the underlying substance use disorder (SUD) at the heart of their problem.

Why does care for patients with SUD hospitalized with serious infections so often come up deficient? In part, because we have socialized rather than medicalized SUD (e.g. cast SUD as an inherent character flaw or immutable condition rather than a treatable physiologic disorder, like infection). The use of stigmatizing language in the medical record – “drug abuser” and “addict” – elicits negative associations among healthcare professionals. As a result, patients with endocarditis related to injection drug use are likely to receive antibiotics but exceedingly unlikely to receive a comprehensive plan of care for their SUD, such as Addiction Medicine or Addiction Psychiatry consultation, medication-assisted treatment, rescue naloxone, or education about safe injection practices and services.

So what does usual care for our patient look like in the US? He will receive IV antibiotics and surgery. Several folks will describe him as an addict in the chart and eventually someone will do it to his face, which will reinforce that his doctors don’t think much of him. The beginning and end of the plan for his SUD will be to tell him that if he wants to live he needs to stop using drugs. Later, he’ll be told that he needs to stay in the hospital for 6 weeks of IV antibiotics (no one will mention the option of letting him finish his IV antibiotics at home with a PICC, because of anxiety that he might inject his drugs through the catheter). At some point, our patient will become so frustrated about languishing in the hospital with no treatment of his SUD that he will leave against medical advice. Perhaps his doctors will write a prescription for oral antibiotics that he may or may not hear about or go pick up, and perhaps he will come back with renewed infection in a week or two, and probably his treatment team will feel that they did their best and will absolve themselves of culpability, saying something like, well, at the end of the day we can’t stop people from making poor life choices.

As an ID physician, and also the medical director of UNMC’s OPAT (home IV antibiotic) program, I think we can do better. First, let’s address the anxiety about PICCs and home IV antibiotic in people who inject drugs (PID). Suzuki et al found that the available data indicates that PID have low (0-2%) rates of PICC misuse with no greater incidence of line infection or thromboembolism than non-PID and similar rates of treatment completion, rehospitalization, disease relapse, and mortality. While other data suggest that OPAT in PID may be labor-intensive on account of more frequent missed visits, line infections, and re-admissions, we must weight these adverse events against the unmeasured adverse events of prolonged hospitalizations: namely, treatment non-completion and failures due to patients leaving AMA, nosocomial infections, and uncontrolled costs. Fortunately, Eaton et al at the University of Alabama at Birmingham have validated a risk assessment tool identifying PID likely to do well with OPAT, and Fanucchi et al showed in a pilot randomized trial that combining OPAT with pharmacologic therapy for SUD in patients with severe injection-related infections resulted in similar infection and drug use outcomes to standard care while shortening hospitalizations by more than three weeks.

The key to success in treating severe injection-related infections in PID is to generate a comprehensive plan for both the patient’s infection and their SUD – and specifically, to offer the patient effective treatment for their SUD that results in harm reduction (i.e. helping these folks to either stop injecting drugs or inject less frequently or in a manner that reduces their risk of developing infections). While SUD treatment is not inherently beyond the scope of infectious disease specialists, here at UNMC we’re blessed with a dedicated Addiction Psychiatry service headed by Drs. Alëna Balasanova and VaKara Meyer Karre.

Starting in Fall 2019, the UNMC ID OPAT team and the Addiction Psychiatry service began working together to identify patients with opioid use disorder severe injection-related infections who, based on the work by Eaton and our own clinical experience, appear likely to do well with early hospital discharge and combination OPAT/MAT. We combine inpatient consultation by Addiction Psychiatry and ID with early (1-2 weeks) follow-up in both ID and psychiatry clinics to help these patients engage and remain in care for both their infection and substance use issues. We believe this approach helps UNMC provide some of our most stigmatized patients with extraordinary care.