While statistics about overdose deaths from the opioid epidemic continue to dominate headlines, other debilitating and costly problems have been creeping up in the shadows. Doctors across the country including here in Cleveland are increasingly worried about the rise of bacterial infections attacking the heart valves of IV drug users – a condition known as infective endocarditis.
“We’re seeing an explosion of patients, some of them very young coming in with infected heart valves,” said Dr. Steven Nissen, chair of the Department of Cardiovascular Medicine at the Cleveland Clinic. The pathway to these infections often starts with a dirty needle or contaminated drug. The bacteria – which is often staph – gets into the bloodstream and then attaches to the valve, he explained.
“The valve is literally being eaten alive by the bacteria,” Nissen said. “It eats away at the valve. It eats away the tissue around the valve.”
The Cleveland Clinic says the proportion of its patients with endocarditis who are opioid addicted was 10% in 2014. During the first half of 2017 it was 18%. Other hospitals including Massachusetts General, as well as Brigham and Women’s in Boston, have noted similar trends.
It's a very pressing issue according to Dr. Thoralf Sundt, chair of cardiac surgery at Mass General. “We looked at patients undergoing surgery for endocarditis at our institutions and saw an increase in the percentage of patients almost doubling of patients with endocarditis for whom it appeared that intravenous drug use was the underlying cause,” he said.
These cases are difficult to treat and often call for open heart surgery so doctors can replace or repair the damaged valves. Doctors say the cost of a single surgery can run over $100,000. The cost of an episode often runs much higher because patients come in very sick – often in respiratory distress – and need to spend days or even weeks in intensive care units. Nissen says in some cases patients die or suffer strokes because pieces of bacteria from the accumulation on the valve break off and travel to the brain. “So we have people sometimes, you know, in their late teens or early 20s – young people using heroin. They get their valve infected and they come in when they've had a stroke,” Nissen added.
Sundt remarked on the human toll these cases exact because so many patients are young and have families with young children. He added, “The social cost is devastating. The health care cost is enormous too.” A study on endocarditis patients in North Carolina who were IV drug users found over 40% were on Medicaid or lacked health insurance. Doctors are increasingly concerned about the number of repeat operations being performed because the patients go back to using drugs and the new valve gets re-infected.
“We have seen a fairly significant number of patients that have had not one not two but three or four heart valve replacements related to repeated use,” said Nissen.
A study at the Cleveland Clinic found that between three and six months after surgery endocarditis patients who use IV drugs had a tenfold increased chance of reinfection or death compared to those who do not use drugs. Another study done by Boston researchers found poor long term results for such patients ten years after surgery, noted Sundt. He said, “93% of patients who used intravenous drugs by the 10 year mark had suffered either death, reinfection or reoperation.”
These cases raise some thorny ethical issues according to Professor Mark Aulisio, head of bioethics at the Case Western Reserve University School of Medicine. Aulisio explained that repeat surgeries may be medically inappropriate for some patients because the burden of the procedure is too great compared to the benefit it may hold. Aulisio also emphasized the high rate of reinfection among IV drug users speaks to the need for treatment guidelines that call for incorporating addiction treatment into the heart care protocol.
“There's really got to be comprehensive care for patients who have this issue,” he said. “Because if there's not you're going to put them through a lot of pain, some suffering, and a difficult road for little – and in some cases – maybe no benefit.”
Sundt said Mass General is in the process of implementing addiction services into its treatment protocol and that it should be the standard of care. Dr. Steven Gordon, chair of Infectious Disease at the Cleveland Clinic said their doctors have also started including addiction treatment upfront for such patients which can include putting patients on Suboxone or other medicines for opioid use disorder. Gordon added, “With no barriers to getting started in the hospital which is relatively novel. But lots of hospitals are looking at that.”
Sundt added, “I think that that's one of the debates that you'll see on the national scene. This is a question of how many times can we redo these heart valve procedures again when we're not really adequately treating the underlying condition which is the addiction.” He continued, “Our money would be much more wisely spent trying to help cure the underlying problem which is the addiction rather than allowing the infections to recur.”
“The ongoing both cost and human suffering related to these infected heart valves is a legacy that will continue even if we stop the epidemic tomorrow,” remarked Nissen. “This is a ripple effect that keeps on growing.”