How Many Chances Are Too Many? Treating Recurrent Infective Endocarditis in IV Drug Users

Some of the most difficult clinical cases I have faced as a cardiologist have been patients presenting with endocarditis secondary to intravenous (IV) drug use.

One patient we cared for developed such extensive disease that the fibrous skeleton that holds the heart together was falling apart, leaving very little viable tissue to enable the surgeon to sew in a new valve. While that patient did not survive, many others who did faced serious adverse consequences. Some patients developed septic emboli that caused strokes and severe morbidity. Often, IV drug users returned with recurrent endocarditis due to their continued drug use. My colleagues and I treated them as best we could with IV antibiotics; sometimes we took them back to the operating room for redo valve replacements. Those rare cases were often the source of intense but fleeting ethical debates among caring physicians. In a recent New York Times article, journalist Abby Goodnough addressed one of those heated questions: how many second chances should a drug user get?¹

Ms Goodnough shares the story of a 28-year-old mother who developed endocarditis after injecting IV methamphetamines. The patient was warned that if she ever developed endocarditis again due to IV drug use, the doctors would not operate on her.¹ The question at the heart of the article — the number of chances a patient has to receive treatment ­— sparked some controversy, resulting in several opinionated letters to the editor by physicians who disagreed with the surgeon’s point of view. Ravi N. Shah, MD, a psychiatrist at the Columbia University Irving Medical Center in New York, argued that while better treatments and public health services are needed to treat addiction, the interim solution of denying care to patients with multiple episodes of drug-induced endocarditis would be akin to abandoning them.² Dr Shah points out that these discussions do not occur regarding patients with myocardial infarctions who are noncompliant with medical therapy and dietary changes. In a beautifully worded final paragraph to the editor, he writes:

“How many chances should a user get? The same number as a smoker with cancer, a drunken driver in an accident, and a father after a heart attack. The same number you would want for your loved one.”²

However, we do not live in a world of unlimited resources — or even of universal access to care. Simply put, as health care gets more expensive, access to available healthcare resources declines. Sarah C. Hull, MD, MBE, of Yale-New Haven Hospital and Farid Jadbabie, MD, of the West Haven VA Medical Center in Connecticut argued this precise point in an article examining ethics in cardiothoracic surgery published in the Annals of Thoracic Surgery in 2014: Drs Hull and Jadbabie point out that futile care increases the overall cost of health care, eventually leading to worse outcomes for everyone through reduced access.³

Drs Hull and Jadbabie reason that physicians do have an obligation to provide the best care possible regardless of circumstances, and that physicians should not be judgmental when delivering that care. However, physicians also have a responsibility to look after the healthcare system as a whole and a duty to not waste resources when they are unlikely to have significant benefit.³ In fact, physicians make these decisions all the time — and may not realize that they’re making them. Organ transplants, for instance, are resource-intensive endeavors; the number of patients who need a transplant far exceeds the number of organs available for transplantation. Many patients with organ failure requiring transplants do not qualify for a transplant if they are current drug users, smokers, morbidly obese, lack health insurance, or have poor social support. It is not that physicians are being judgmental — it is just a fact that without certain favorable factors, these patients will not successfully survive organ transplantation.

Another example is when a non-compliant patient who had a myocardial infarction comes back in with in-stent thrombosis after stopping dual antiplatelet therapy (DAPT). Most interventionalists will not place another drug-eluting stent because doing so might kill the patient if they decide to stop their DAPT again. In such cases, patients might be referred to less than ideal coronary bypass surgery or an older generation bare metal stent because those options are less risky in the event that the patient continues to be non-compliant with their therapy.

Is Dr Shah’s response wrong? Absolutely not. The answer is somewhere between the two viewpoints. Dr Shah is right in that drug addicts have a disease that is poorly treated. As a country, a healthcare system, and as physicians we’ve done a horrible job of dealing with drug addiction. Take for instance the opioid epidemic: we let the pharmaceutical industry convince us that we did not know how to adequately manage pain when we should have pushed back. Now that we’ve recognized the problem, physician interest groups are blocking Congress from enacting possible solutions.⁴

What about the ridiculous state of the drug rehabilitation industry, which has been incentivized to allow patients to relapse?⁵ It is an extraordinarily unregulated industry that generates massive profits by doing absolutely nothing to help prevent patients from relapsing. In fact, the situation is so absurd that even John Oliver decided to take a serious look at it in a recent episode of Last Week Tonight on HBO.

So, in Dr Shah’s defense, sure we should be better stewards of health care and not waste resources, but how can we justify the worry about how many times should we operate on a drug user when we are wasting more resources and allowing the rehab industry to run amok? Surgeons want these patients to do well and not come back with recurrent endocarditis. But, to be successful, patients need good drug rehabilitation to treat their addiction; however, the drug rehab industry is incentivized to let patients relapse, which increases their risk for developing endocarditis again. As physicians, we cannot step away from this situation and say “It was the patient’s fault, we warned him.” That would be like denying treatment to a person with diabetes who continues to experience diabetic ketoacidosis — and then sending them off into a mall filled with candy stores armed only with a syringe filled with saline instead of insulin.

In another letter to the editor published in the New York Times, Widney Brown, JD, managing director for policy at the Drug Policy Alliance, points to the underlying problem: the stigma and implicit bias that we as clinicians have against drug users.⁶ Ms Brown makes an excellent case by pointing to professional athletes as an example of a situation in which we repeatedly perform procedures to treat behavior-related injuries and do not question when enough is enough. We offer athletes tactics to reduce their risk for injury, but we do very little to help drug users reduce their risk for infection and death from IV drug use. Offering clean needle exchanges is a cheap and simple way to reduce the risk for endocarditis, but our societal stigma against drug users keeps us from politically supporting evidence-based solutions. 

How many second chances should a drug user get? As many as it takes for us — physicians, society, government, and the healthcare system — to get it right. 

References

1. Goodnough A. Injecting drugs can ruin a heart. How many second chances should a user get? New York Times. www.nytimes.com/2018/04/29/health/drugs-opioids-addiction-heart-endocarditis.html. Published April 29, 2018. Accessed May 31, 2018.
2. Shah RN. How many chances should a drug user get? Letters to the Editor. New York Times. www.nytimes.com/2018/05/06/opinion/drug-user-heart.html. Published May 6, 2018. Accessed May 31, 2018.
3. Hull SC, Jadbabaie F. When is enough enough? The dilemma of valve replacement in a recidivist intravenous drug user. Ann Thorac Surg. 2014;97(5):1486-1487
4. Kucinich J. Congress is “too scared” of the AMA to really attack opioids. The Daily Beast. www.thedailybeast.com/congress-is-too-scared-of-the-ama-to-really-attack-opioids. Published May 29, 2018. Accessed May 31, 2018.
5. Harris AJ, Walter S. How a rehab boss exploited the drug epidemic — with impunity. Associated Press. www.apnews.com/b3f1bb52163148d2a7a08e5af25db308/. Published May 21, 2018. Accessed May 31, 2018.
6. Brown W. How many chances should a drug user get? Letters to the Editor. New York Times. www.nytimes.com/2018/05/06/opinion/drug-user-heart.html. Published May 6, 2018. Accessed May 31, 2018.