A life-threatening heart infection afflicts a growing number of people who inject opioids or meth. Costly surgery can fix it, but the addiction often goes unaddressed.
Dr. Thomas Pollard, a cardiothoracic surgeon in Knoxville, Tenn., and his team working to replace heart valves that had been damaged from endocarditis, an infection the patient developed from injecting drugs. Shawn Poynter for The New York Times
OAK RIDGE, Tenn. — Jerika Whitefield’s memories of the infection that almost killed her are muddled, except for a few. Her young children peering at her in the hospital bed. Her stepfather wrapping her limp arms around the baby. Her whispered appeal to a skeptical nurse: “Please don’t let me die. I promise, I won’t ever do it again.”
Ms. Whitefield, 28, had developed endocarditis, an infection of the heart valves caused by bacteria that entered her blood when she injected methamphetamine one morning in 2016. Doctors saved her life with open-heart surgery, but before operating, they gave her a jolting warning: If she continued shooting up and got reinfected, they would not operate again.
With meth resurgent and the opioid crisis showing no sign of abating, a growing number of people are getting endocarditis from injecting the drugs — sometimes repeatedly if they continue shooting up. Many are uninsured, and the care they need is expensive, intensive and often lasts months. All of this has doctors grappling with an ethically fraught question: Is a heart ever not worth fixing?
“We’ve literally had some continue using drugs while in the hospital,” said Dr. Thomas Pollard, a veteran cardiothoracic surgeon in Knoxville, Tenn. “That’s like trying to do a liver transplant on someone who’s drinking a fifth of vodka on the stretcher.”
The problem has consumed Dr. Pollard, a calm Texan who got his Tennessee medical license in 1996, just after the widely abused opioid painkiller OxyContin hit the market. He has seen an explosion of endocarditis cases, particularly among poor, young drug users whose hearts can usually be salvaged, but whose addiction goes unaddressed by a medical system that rarely takes responsibility for treating it.
Certain cases haunt him. A little over a year ago, he replaced a heart valve in a 25-year-old man who had injected drugs, only to see him return a few months later. Now two valves, including the new one, were badly infected, and his urine tested positive for illicit drugs. Dr. Pollard declined to operate a second time, and the patient died at a hospice.
“It was one of the hardest things I’ve ever had to do,” he said.
The Treatment Gap
As cases have multiplied around the country, doctors who used to only occasionally encounter endocarditis in patients who injected drugs are hungry for guidance. A recent study found that at two Boston hospitals, only 7 percent of endocarditis patients who were IV drug users survived for a decade without reinfection or other complications, compared with 41 percent of patients who were not IV drug users. Those hospitals are among a small but growing group trying to be more proactive.
Dr. Pollard has been lobbying hospital systems in Knoxville to provide addiction treatment for willing endocarditis patients, at least on a trial basis, after their surgery. If the hospitals offered it, he reasons, doctors would have more justification for turning away patients who refused and in the long run, hospitals would save money.
Addiction has long afflicted rural east Tennessee, where the rolling hills and mountains are woven with small towns suffering from poverty and poor health. Prescribing rates for opioids are still strikingly high, and the overdose death rate in Roane County, where Ms. Whitefield lives, is three times the national average. Jobs go unfilled here because, employers say, applicants often cannot pass a drug test.
Across Tennessee, some 163,000 poor adults remain uninsured after state lawmakers refused to expand Medicaid under the Affordable Care Act. For them, and even for many covered by Medicaid, as Ms. Whitefield is, evidence-based opioid addiction treatment remains meager. More common are cash-only clinics, or abstinence-based programs that bank on willpower instead of the addiction medications that have proved more effective.
Treatment for endocarditis usually involves up to six weeks of intravenous antibiotics, often in the hospital because doctors are wary of sending addicted patients home with IV lines for fear they would use them to inject illicit drugs. Many, like Ms. Whitefield, also need intricate surgery to repair or replace damaged heart valves. The cost can easily top $150,000, Dr. Pollard said.
Advice from specialty groups, like the American Association for Thoracic Surgery and the American College of Cardiology, about when to operate remains vague. For now, “it’s just a lot of anecdote — surgeons talking to each other, trying to determine when we should and when we shouldn’t,” said Dr. Carlo Martinez, who is one of Dr. Pollard’s partners and who operated on Ms. Whitefield at Methodist Medical Center of Oak Ridge.
Their practice, owned by Covenant Health, will almost always operate on someone with a first-time case of endocarditis from injecting drugs, Dr. Pollard said. But repeat infections, when the damage can be more extensive and harder to fix, make it a tougher call. Dr. Mark Browne, Covenant’s senior vice president and chief medical officer, said, “Each patient is evaluated individually and decisions regarding the appropriate course of care are determined by their attending physician.”
In the nearly two years since she got sick, Ms. Whitefield has felt physically diminished and been prone to illness. She also feels harshly judged by a medical system that saved her life but often treats her with suspicion and disdain.
Over the same stretch of time, Dr. Pollard has grown increasingly disillusioned with hospitals that consider addiction treatment beyond their purview, and haunted by the likelihood that many of his drug-addicted patients will die young whether they get heart surgery or not. He set up a task force in 2016 to address the problem but has faced obstacles, especially concerning cost and, he believes, a societal reluctance to spend money on people who abuse drugs.
“Everybody has sympathy for babies and children,” he said. “No one wants to help the adult drug addict because the thought is they did this to themselves.”
Dr. Pollard has been consumed by the problem of endocarditis among drug users whose addiction goes unaddressed. “We’ve literally had some continue using drugs while in the hospital,” he said. Joe Buglewicz for The New York Times
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Ms. Whitefield, a talkative young woman with brooding eyes, goes by the nickname Shae. She started on opioid painkillers as a teenager suffering from endometriosis, a disorder of the uterine tissue, and interstitial cystitis, a painful bladder condition. She got the opioids from doctors for years, and eventually from friends.
She and her high school boyfriend, Chris Bunch, had three children by the time she was 26. She trained to become a licensed practical nurse but dropped out of the program when her oldest son, Jayden, got seriously ill as a baby. The family lives in a tiny town that Mr. Bunch, now Ms. Whitefield’s husband, described as “country, country, country.”
In 2015, after their daughter, Kyzia, was born, Ms. Whitefield sank into postpartum depression. She was obsessively worried about shielding Kyzia from sexual abuse and other traumas she had experienced as a child. She started injecting crushed opioid pills and occasionally meth, savoring the needle’s sting — she had an old habit of cutting herself to provide relief from emotional pain — at least as much as the high.
After sharing a needle with one of her brothers that day in June 2016, Ms. Whitefield started shivering and sweating. A fever soon followed, and she lay for almost a week on the couch, thinking she had a kidney infection. She was delirious by the time Jayden, then 8, woke her stepfather one morning and told him to call 911.
She arrived at Methodist Medical Center of Oak Ridge with full-blown sepsis, floating in and out of consciousness. Her organs had started to shut down.
At home, she had stared at a picture on the wall of her grandmother faintly smiling, a source of reassurance, for days. When the first nurse leaned over her in the emergency room, she thought she smelled her grandmother’s perfume.
Her stepfather, Brian Mignogna, remembers being stunned when a doctor who initially assessed her said that if it were up to him, he would not go to great lengths to save her.
“He said once someone’s been shooting up, you go through all this money and surgery and they go right back to shooting up again, so it’s not worth it,” Mr. Mignogna recalled. “I was just dumbfounded.”
Dr. Martinez was the on-call heart surgeon a few days later, though, and felt strongly about taking Ms. Whitefield’s case. Her children and stepfather had been constants at her bedside, and unlike some patients he had seen, she had readily admitted to her drug use. He believed her when she said she had not been injecting for long and wanted to stop.
“She was a young mother and her family was involved; her father was there,” he said. “To me, it seemed she had that social support that patients need once they recover from this.”
Ms. Whitefield also had health coverage through Medicaid, the government insurance program for the poor, because she has young children. It paid for her care, whereas if she were uninsured, the hospital would have had to cover the cost.
Antibiotics cleared the infection that initially led her to the hospital, but she ended up needing surgery two months later. Her mitral valve was so damaged that she had begun showing signs of heart failure. Dr. Martinez was compassionate, but he stressed that the surgery would be “a one-time deal,” Mr. Mignogna recalled.
“The way he put it was, ‘You relapse and end up with another infection, we won’t treat you again,’” Mr. Mignogna said.
Dr. Martinez repaired Ms. Whitehead’s mitral valve in a three-hour operation. It involved sawing open her breastbone, connecting her to a bypass machine to keep blood flowing through her body, and then stopping her heart and fixing the valve. He reinforced it with a small plastic ring before restarting her heart and closing her up.
She had written a note to each of her children — wise Jayden, kind Elijah, strong-willed Kyzia — in case she never woke up. Two weeks later, she was well enough to go home. She soon began seeing a counselor at a clinic unaffiliated with the hospital system and taking buprenorphine, a medication that diminishes opioid cravings and has been found to reduce the risk of relapse and fatal overdose.
Ms. Whitefield has had occasional cravings since the surgery but says she has not used drugs again, traumatized by the memory of her ordeal.
“I know next time God might not save me,” she said quietly. “They will not treat me for a second time if I have track marks or anything like that.”
As she recuperated, Ms. Whitefield started thinking about returning to school, aspiring to become a drug and alcohol counselor or real estate agent, or both.
She has also started serving as an advocate of sorts for others in her community who get endocarditis or other infections from injecting, driving them to the emergency room or sharing every detail of the protocol that saved her. She smarts at the thought of providing only “comfort care” — antibiotics but no surgery — even if a patient refuses addiction treatment.
“When do you stop wanting to save a life?” she asked. “If you have that ability, who’s to say you shouldn’t use it? I see it from their standpoint — not wanting to repeat the same game. But it’s hard, you know? This isn’t an easy disease to break away from.”
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Dr. Pollard, a quietly driven high school valedictorian, used to have no empathy for drug-addicted patients.
“I was like everyone else: ‘They do it to themselves, they deserve what they get,’” he said. “But then when you see their children, and hear about friends my kids went to school with who have died, it’s closer to home.”
When he became president of the Knoxville Academy of Medicine in 2015, he came up with the idea of the city’s hospital systems teaming up to offer addiction treatment to endocarditis patients. He had the perfect platform to push for it, he thought.
So the following year, he set up a task force that included people from each hospital system — his own, Covenant Health; the University of Tennessee Medical Center; and Tennova Healthcare — as well as from two drug treatment centers and some community groups.
At a task force meeting last August, about a year after Ms. Whitefield’s surgery, Dr. Pollard clicked through a PowerPoint presentation full of data a research nurse had compiled. From 2014 through 2016, the three hospital systems in Knoxville had provided valve surgery to 117 patients diagnosed with endocarditis from injecting drugs. Ten had received a second surgery after becoming reinfected; of those, two had received a third.
Just over half the patients were uninsured, and only 1 percent had private coverage. From the data, it was impossible to know if anyone had been reinfected but turned away by doctors. But at least 21 people — 18 percent — had died since their heart surgery, typically from sepsis or respiratory failure, which Dr. Pollard said indicated reinfection.
The group discussed Dr. Pollard’s proposal for Cornerstone of Recovery, an addiction treatment center here, to admit a handful of endocarditis patients as soon as they were cleared for discharge. Cornerstone would provide several months of inpatient treatment and up to a year’s worth of Vivitrol, a monthly $1,000 shot that blocks cravings and helps prevent relapse.
Buprenorphine, the medication Ms. Whitefield takes, is less expensive. But Cornerstone does not provide it because it is an opioid itself and “is trading one for the other,” said Webster Bailey, its executive director of marketing. Many addiction experts have called that view “grossly inaccurate.” They say it is weaker than drugs like oxycodone and heroin, activating the brain’s opioid receptors enough to ease cravings but not enough to provide a high in people who are already dependent on opioids.
Patients would sign an agreement stating that if they returned to abusing drugs after addiction treatment, they might not be considered a candidate for future heart surgery. The total cost per patient: perhaps $55,000, which Dr. Pollard hopes that government and private funding would help cover if the program expanded.
“This should be part of the treatment, just like antibiotics are,” he told the group.
A surgeon from Tennova dryly pointed out: “Not everybody in that group is going to say, ‘This is for me, I’m going to do it.’”
Still, the group decided Dr. Pollard should take the next step, pitching the pilot plan to each system’s top executives.
“We are competing systems, but this is a common enemy that unites us all,” he said afterward. “We need a united policy.”
Source: https://www.nytimes.com/2018/04/29/health/drugs-opioids-addiction-heart-endocarditis.html April 2018
