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• Multidisciplinary infective endocarditis care teams should address substance use disorders and harm reduction services
  Thomas D. Brothers, Duncan Webster
  Published on: 10 November 2018

• Published on: 10 November 2018

  Multidisciplinary infective endocarditis care teams should address substance use disorders and harm reduction services

  • Thomas D. Brothers, Resident physician Department of Medicine, Dalhousie University, Halifax, Nova Scotia, Canada
  • Other Contributors:
    • Duncan Webster, Associate Professor

  We read with great interest Kaura and colleagues’ evaluation of a multidisciplinary care team for hospital inpatients with infective endocarditis (IE) (1). The study provides further evidence for the effectiveness of a team-based approach to IE care – a model endorsed by both European (2) and American (3) guidelines. Despite limitations inherent in a before-and-after study design, it is clear that the IE team provides patients rapid access to cardiology, microbiology, and surgical care with coordination between services.

  Notably absent from this multidisciplinary approach, however, is care for substance use disorders. We wish to draw readers’ attention to the 10% of study participants for whom injection drug use (IDU) was identified as a predisposing factor in their IE. We believe a coordinated IE team offers enormous potential to provide addictions care and harm reduction services for patients with IE who inject drugs.

  Compared with people who do not inject drugs, people who inject drugs are far more likely to have recurrences and repeat hospitalizations for IE, and face increased mortality risk after a first episode of IE (4,5). Rates of hospitalization for IDU-associated IE also appear to be increasing (4,6–8).

  Evidence-based interventions can be provided in-hospital to reduce both rates of injecting and harms associated with ongoing injection. These interventions include initiating opioid agonist therapies (e.g. methadone or buprenorphine) for opi...

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  We read with great interest Kaura and colleagues’ evaluation of a multidisciplinary care team for hospital inpatients with infective endocarditis (IE) (1). The study provides further evidence for the effectiveness of a team-based approach to IE care – a model endorsed by both European (2) and American (3) guidelines. Despite limitations inherent in a before-and-after study design, it is clear that the IE team provides patients rapid access to cardiology, microbiology, and surgical care with coordination between services.

  Notably absent from this multidisciplinary approach, however, is care for substance use disorders. We wish to draw readers’ attention to the 10% of study participants for whom injection drug use (IDU) was identified as a predisposing factor in their IE. We believe a coordinated IE team offers enormous potential to provide addictions care and harm reduction services for patients with IE who inject drugs.

  Compared with people who do not inject drugs, people who inject drugs are far more likely to have recurrences and repeat hospitalizations for IE, and face increased mortality risk after a first episode of IE (4,5). Rates of hospitalization for IDU-associated IE also appear to be increasing (4,6–8).

  Evidence-based interventions can be provided in-hospital to reduce both rates of injecting and harms associated with ongoing injection. These interventions include initiating opioid agonist therapies (e.g. methadone or buprenorphine) for opioid use disorders, providing sterile injecting equipment (e.g. needles, syringes, water, cleaning swabs, cookers, and ascorbic acid), and counselling patients on safer injecting practices to reduce risks of infection (9–15).

  Hospital admissions for IDU-associated IE represent an opportunity for clinicians to reach patients who are less likely to seek medical attention, and for many patients may provide new motivation to engage in treatment for substance use disorders (16–23). Treatment of acute opioid withdrawal at the time of admission, managing the substance use disorder, and establishing a therapeutic alliance can help to improve adherence to medical management of IE and avoid unplanned discharges against medical advice that often result from active, untreated substance use disorders (10,13,16,18,19,24–31).

  Unfortunately, inpatient treatment for IDU-associated IE often focuses on the infection and the medical sequelae without addressing the underlying substance use disorder (9,28,32–35). For example, in a recent study of patients treated for IDU-associated IE at a Boston hospital, only 8% had a plan for opioid agonist therapy at the time of discharge (32).

  There are multiple reasons for this implementation gap (28,35). Most physicians do not feel competent in addictions care (36,37). Jurisdictions have different limitations on methadone or buprenorphine prescribing, and institutions may not have clear pathways to identify community-based clinicians to continue prescribing opioid agonist therapy following hospital discharge (38,39). In our institutions (which do not yet have multidisciplinary IE care teams), patients with IE may be admitted or discharged through internal medicine, cardiology, cardiac surgery, or critical care, with ad hoc coordination between those services along with infectious diseases or medical microbiology. Each service may feel that the substance use disorder underlying the IE, and the associated increased risks of recurrence and mortality, are not within their scope of practice and are not the responsibility of their particular discipline (34). Clearly reducing these risks is in the best interests of our patients and our communities – so whose responsibility will it be?

  While the European and American endocarditis guidelines do not specify how addiction medicine could fit into multidisciplinary IE care teams, recommendations from the British Heart Valve Society specify that all patients with IE who inject drugs should be offered addictions care (40). National and international IE guidelines should consider injection drug use as an important co-morbidity to address as part of patient-centred IE care.

  A coordinated, multidisciplinary care team responsible for all inpatients with IE represents an indispensable opportunity to integrate addiction medicine expertise and offer care for substance use disorders to every patient with IE who injects drugs. An IE team should help facilitate initiation of opioid agonist therapy and promote other harm reduction strategies during hospital admissions in order to reduce the heightened risks of early hospital discharges against medical advice, recurrent infective endocarditis, and mortality. This approach could prolong life and reduce suffering for our patients with IE who inject drugs.

  References

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  2. Habib G, Lancellotti P, Antunes MJ, Bongiorni MG, Casalta J-P, Del Zotti F, et al. 2015 ESC Guidelines for the management of infective endocarditis: The Task Force for the Management of Infective Endocarditis of the European Society of Cardiology (ESC). Endorsed by: European Association for Cardio-Thoracic Surgery (EACTS), the European Association of Nuclear Medicine (EANM). Eur Heart J. 2015 Nov 21;36(44):3075–128.

  3. Nishimura RA, Otto CM, Bonow RO, Carabello BA, Erwin JP, Fleisher LA, et al. 2017 AHA/ACC Focused Update of the 2014 AHA/ACC Guideline for the Management of Patients With Valvular Heart Disease: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. Circulation. 2017 Jun 20;135(25):e1159–95.

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  15. CATIE. Best Practice Recommendations for Canadian Harm Reduction Programs. 2015 September 16. Available from: http://www.catie.ca/en/programming/best-practices-harm-reduction

  16. Velez CM, Nicolaidis C, Korthuis PT, Englander H. “It’s been an Experience, a Life Learning Experience”: A Qualitative Study of Hospitalized Patients with Substance Use Disorders. J Gen Intern Med. 2017 Mar;32(3):296–303.

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  24. Pauly B (Bernie), McCall J, Browne AJ, Parker J, Mollison A. Toward Cultural Safety: Nurse and Patient Perceptions of Illicit Substance Use in a Hospitalized Setting. Adv Nurs Sci. 2015;38(2):121–35.

  25. Merrill JO, Rhodes LA, Deyo RA, Marlatt GA, Bradley KA. Mutual Mistrust in the Medical Care of Drug Users. The Keys to the “Narc” Cabinet. J Gen Intern Med. 2002 May;17(5):327–33.

  26. Aszalos R, McDuff DR, Weintraub E, Montoya I, Schwartz R. Engaging hospitalized heroin-dependent patients into substance abuse treatment. J Subst Abuse Treat. 1999 Sep;17(1-2):149–58.

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  30. Chan ACH, Palepu A, Guh DP, Sun H, Schechter MT, O’shaughnessy MV, et al. HIV-positive Injection Drug Users Who Leave the Hospital Against Medical Advice: The Mitigating Role of Methadone and Social Support. Jaids J Acquir Immune Defic Syndr. 2004 Jan 1;35(1):56–9.

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  Conflict of Interest:
  None declared.

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