Docs Debate Surgery on Opioid Users

USA TODAY NETWORK – TENNESSEE

A spike in the number of patients coming in with infected heart valves has surgeons speaking up -- because even if the expensive and involved surgery is successful, many of these patients, who inject opioid drugs in their veins or under their skin, still will die young.

That leaves doctors and hospital systems grappling with the ethics of when – or if – to replace the heart valves of IV drug users who may come in months later with the replacement valve infected.

“It’s not a high-mortality surgery,” said cardiothoracic surgeon Dr. Thomas Pollard. “The reason the mortality is so high in these patients is because they go back to their drug use.”

Increase tied to epidemic

Endocarditis, in which a bacterial infection introduced through the blood stream attaches to heart tissue and destroys it, has been linked to IV drug use for decades.

But until five years ago, drug-related cases were the minority. More commonly, patients would get bacteria in their blood stream via a serious cut or an infection like pneumonia, or sometimes after a dental problem or medical procedure.

Those patients who got endocarditis other than through drug use – especially young ones – almost always not only survived the surgery but had “a good outcome and probably a normal life expectancy,” said Pollard, who’s practiced in several Knoxville-area hospitals and is now at Parkwest Medical Center.

But as the opioid epidemic tightens its grip on East Tennessee, Pollard has seen the number of IV drug users needing the heart valve replacement surgery skyrocket – costing hospitals hundreds of thousands of dollars in uncompensated costs, and forcing doctors to discuss whether to do a complicated, costly procedure on a patient who is likely to come back in a few months and need it all over again, with even higher cost and risk.

The complexities of addiction

University of Tennessee cardiothoracic surgeon Dr. Lawrence Lee has seen that happen more than once.

“We can do this high-risk surgery and give them a new heart valve, but if we operate and get them through the surgery, they go right back to using drugs,” Lee said. “We’ve had people reuse within a week of going home. If they infect the (replacement) tissue valve, that’s even harder to treat.”

Most patients are in their 20s and 30s, he said. If they’re using drugs, they typically don’t have health insurance or money.

Because replacement heart valves made of human or animal tissue tend to wear out more quickly, Pollard might ordinarily use a mechanical valve for younger patients – but that’s not an option for patients who aren’t likely to take a daily blood thinner as prescribed.

And while some insurance policies will cover daily IV antibiotics through home health, doctors don’t like to send known IV drug abusers home with IVs in.

“We have to trust the patient at some point, but we’ve got so much invested in this patient,” said Pollard. “Realistically, it doesn’t matter: If they’re going to take drugs, they’re going to do it” – sometimes even sneaking illicit drugs into their hospital rooms.

If they do keep using, he said, their survival rate plummets. At five years post-operation in these patients, Pollard said, 7 percent are alive and sober.

“If I told any hospital administrator, ‘I have this great operation or treatment that’s going to have a 7 percent success rate, they’d laugh me out of their office,” Pollard said. “We wouldn’t do that. And yet, that’s what we’ve done for decades.”

Hard questions for doctors

There’s very little medical research or scientific studies about best practice of treating both the infection and addiction, save for a paper out of Boston in which hospitals pooled their experiences. Clinicians struggle to best identify patients for surgery and rehab -- and how to either pair the services or decide if someone is unlikely to get clean, said Dr. Ashish Shah, a cardiac surgeon at Nashville’s Vanderbilt University Medical Center.

“Without resources it’s really a malignant, incurable problem,” Shah said. “No one’s going to get famous from sorting it. No one’s going to get a Nobel Prize for fixing it.”

Pollard chairs the Knoxville Academy of Medicine’s Endocarditis Project, a task force hoping to come up with guidelines about how to ethically but responsibly treat – or not treat – active drug users with endocarditis. The group includes surgeons, hospital administrators, addiction treatment specialists, ethicists and lawyers.

The group retained a research nurse to get an idea of the scope of the problem. She looked at data from UTMC and hospitals in the Covenant Health and Tennova systems for 2015 and 2016 and found 84 patients with endocarditis who were confirmed IV drug abusers.

Their average hospital stay was 28.7 days. Their average hospital bill – not counting the antibiotics, providers and the valve itself, which runs around $25,000 for a tissue valve – was $55,000. Pollard thinks that estimate is conservative; he knows of at least patient, who had multiple valve replacement surgeries, whose bill topped $250,000.

And 17 of them – more than 20 percent – are dead today.

Widespread challenge

The problem isn’t limited to East Tennessee.

After hearing anecdotes from infectious disease experts across the state, the Tennessee Department of Health is putting together a system to track cases, said Dr. David Reagan, the agency’s chief medical officer.

Meanwhile, Vanderbilt is pulling together interdisciplinary teams that include addiction specialists so heart surgeons aren’t left with the responsibility of deciding whether to offer a surgery to a patient who’s likely to get reinfected, Shah said.

Return patients strain community hospitals, which call larger hospitals – frequently academic medical centerssuch as Vanderbilt and UT -- for help, which strains those resources.

Heart surgeons’ jobs already require them to compartmentalize and make tough decisions, but confronting a decision that is life-or-death yet rooted in problems a surgery can’t fix is demoralizing,Shah said. “Where is that line drawn between futility, costs and taking care of fellow human beings?” Shah said. “It’s a lousy position to be in when you know you could help them in the short-term, but in the long-term you think it’s futile.”

Drug rehab required?

The Knoxville Academy of Medicine task force concluded the only reasonable solution is having these patients commit to drug rehab. And, since Lee and Pollard both say patients turned down at one hospital will “shop” to find another to do the surgery, it has to be a community-wide consensus.

With help from lawyers, the group has drawn up a tentative contract where endocarditis patients would agree to three months of inpatient rehab as a condition of the surgery. Those who don’t sign would get palliative care only.

“I know that some patients will say, ‘Really? Three months in inpatient rehab? I’m not going to do that!’” Pollard said. “With the advice of our ethicists and our attorney, we know that the decision you’ve made will result in a 7 percent success rate, and that’s just not worth doing.

“It’s not that we’re going to turn you away. … Just realize that your condition is like a patient who has terminal cancer. You don’t walk away from them, you don’t stop treating them. But, quite honestly, we’re not going to cure you.”

Inventing new programs

Of course, that solution involves an ongoing problem: where to get rehab for mostly indigent patients – who now have serious medical conditions on top of addiction.

Treating endocarditis along with substance abuse is challenging, said Reagan, because the state doesn’t have enough inpatient rehab beds to accommodate people who need the services. And many facilities are cash-only or require insurance, which prevents a lot of people from accessing the services, Reagan said.

“It’s a terrible paradox,” said Reagan.“I really think that when someone is diagnosed that we ought to be looking at their substance abuse disorder and make that our first priority.”

A program in Baltimore saw results from a system that connected patients to rehab services immediately after surgery, said Shah, who worked for Johns Hopkins University before moving to Nashville. That program worked but fizzled when its funding ran dry, he said.

The Knoxville task force first looked at creating a new facility, perhaps attached to a hospital, Pollard said, but “that was going to be an astronomical cost.”

Now the group is in the “preliminary stages” of a partnership with Blount County-based Cornerstone of Recovery, which already has inpatient rehab. Psychiatrist Dr. Lane Cook has drawn up a proposal for Cornerstone, with support from local hospitals, to run an inpatient unit where patients would get post-operative care and IV antibiotics along with residential substance abuse treatment, in some cases using Vivitrol shots, which uses long-acting naltrexone to block the brain receptor that lets a drug abuser feel pleasure from opioids.

“These are expensive patients to care for, and a major issue is trying to get funding for it,” Cook said. “Grants have been applied for.”

Upon release, they’d be connected with community agencies and halfway houses.

Projected savings: money, lives

Pollard thinks he can make a case to the hospitals that “redirecting” patients to rehab right after surgery would cost less than keeping patients in the hospital five or six weeks – not to mention the savings long-term if patients don’t keep returning with new injection-related problems.

Cook said the problem already costs Knoxville health systems about $750,000 annually.

If the program works, Pollard said, he expects the group to publish results and hopes it will be pilot for other areas with similar issues.

“We have to have a comprehensive treatment plan to help these people,” Lee said. “We’re not doing them any good by fixing their arm abscess or their infected valve and sending them back out where they’re going to use drugs again, with no support.”

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