Should IV drug users receive $$$ endocarditis treatment?

[cduggles]

Doctors Consider Ethics Of Costly Heart Surgery For People Addicted To Opioids

March 21, 20175:00 AM ET
Heard on Morning Edition
JACK RODOLICO
FROM nhpr
Audio File available with link

Milford had endocarditis, which is essentially an abscess on one of his heart valves. He spent seven weeks in the hospital on intravenous antibiotics. Eventually, he went back home. But he kept injecting drugs, and he got endocarditis two more times.

After the third time, Milford quit abusing opioids...

Milford is part of a group of opioid addicts whom doctors describe as the sickest of the sick: intravenous drug users, mostly people who use heroin, who get endocarditis. Some aspects of their treatment present an ethical dilemma for doctors. Cardiologists, surgeons and infectious disease doctors can fix the infection, but not the underlying problem of addiction.

[Cardiologist] Eddinger took lists of patients going back five years and started searching for their names online. "What I did is I went and I used the Internet to figure out if they died afterward," he explains.

He specifically looked for online obituaries for patients who had been intravenous drug users and had heart valves replaced. In 2011, Catholic Medical Center treated three intravenous drug abusers with endocarditis. Last year, it saw 51, most of whom were in their 20s and 30s, and most of whom were on Medicaid.

From his online searches, Eddinger learned 25 percent of his hospital's patients who had been treated for endocarditis and were intravenous drug users had died after leaving the hospital. Looking through his data, he also could see that group had been expensive to treat. For patients who returned to the hospital multiple times, the hospital was charging insurers about half a million dollars...

Nancy Teixeira, the director of Catholic Medical Center's Cardiovascular Surgical Unit, says the treatment for endocarditis does not always work if the patient is an intravenous drug abuser.

"We've had people come in, get their valves done, go back out and use, and they either die or they show up in extremis because they've used again and now they've reinfected their new valve and they're right back at square one," she says.

And surgery isn't risk-free. Scar tissue builds up with each valve replacement.

Catholic Medical Center is one of the first hospitals to write ethical guidelines to help clinicians answer that question. The guidelines call for setting patients up with drug treatment, says Dan Daly, a medical ethicist at Saint Anselm College who helped write them.

Daly says that the guidelines are not some kind of moral test. Instead, they are meant to help doctors connect patients with a primary care physician or set them up with addiction counseling.

"This is not the patient proving to the medical team that they are worthy of a new valve, that they are worthy of the surgery," Daly says. "We wanted to make sure that that could not happen."

Source

 

[cj]

That's billshit. We hat about fat people who have a bypass then keep eating cheeseburgers until they need another bypass should they be let die? What a heartless doctor

 

[elvis_wears_nikes]

That's billshit. We hat about fat people who have a bypass then keep eating cheeseburgers until they need another bypass should they be let die? What a heartless doctor

That is so true. Why should addicts be allowed to suffer even more than they already are. Addiction is a mental health issue and why is it that just because your illness is not 'visible' you should be treated less than human.

 

[Crankinit]

It seems like an effective approach to this dilemma would be to encourage harm reduction among IV drug users, particularly in the form of hygienic injection practices and the use of micron filters.

 

[spacejunk]

^ yep. And better yet would be to prescribe sterile, pharmaceutical grade heroin to these high-risk cases (basically anyone addicted to intravenous heroin).
Prevention > highly problematic and intensive medical treatments

 

[zephyr]

Its antibiotics. Antibiotics are not expensive, nor should iv antibiotics and a basic bed.


USA should go back to the drawing board and figure out why a simple iv antibiotic is so expensive and see what the real issue is.

People using the health system to make a profit. Its ridiculous.

 

[elvis_wears_nikes]

People using the health system to make a profit. Its ridiculous.

Exactly! Not to mention the pharmaceutical companies who try to extort the most vulnerable for money. It's disgusting how they use certain 'market strategies' such as making the life-sustaining antiretroviral HIV medication some of the most expensive drugs as people need to take them every day just to stay alive! $$$

 

[cduggles]

Zephyr: I agree although it seems that there is a long inpatient stay? And I excerpted from the article but I realize I should have included this part regarding complications.

The damage from the three bouts of endocarditis was even worse. When he was just 35 years old, [Milford] had two heart surgeries to implant a pacemaker and replace his infected valve.

He also had a stroke that left him with impaired speech.

The question I was hoping might be addressed is "Would IV drug users be more or less likely to go for treatment for endocarditis (or abscesses, etc.) if referral to an addiction specialist was part of the deal?"

What is offered (ORT, therapy) might not be as desirable as an Rx for pharmaceutical-grade heroin (it's good to dream ), but it does shows an awareness on the part of "the medical system" that not addressing addiction is bad for the patient, the hospital (cost-benefit) and medical providers who care but realize they aren't capable of addressing addiction.

tl;dr No one is proposing that IV drug addicts should not be treated for endocarditis. However, endocarditis, particularly repeated bouts, can be medically complicated and expensive.

Clinician ethics, patient welfare, and economics all align to indicate that addressing the underlying issue of addiction is needed.

How? By referring the patient to addiction counseling, which is vague but at least there's an awareness that it must be addressed in a specialized setting.

Takeaway: Write Jared Kushner.

 

[spacejunk]

it's a tricky part of medical ethics, but there is some comparison that can be made with cigarette smokers and life-saving surgical treatments. i've heard of heart surgeons, for example, telling patients that they are not willing to prioritise the treatment of someone who continues to smoke over another patient who has either quit, or is a non-smoker, for something like a heart bypass
it's complicated because addiction - and its multitude of different facets is a whole other area of medicine in itself that is extraordinarily hard to treat, compounding the complexities and ethical considerations.
i suppose the same could be said of chronic alcoholics with cirrhotic livers; should someone be given a liver transplant if they continue to drink?

the medical and social stigma of addiction - particularly to intravenous drugs - is enormous, but there are practical considerations which need to be accounted for as well. it's not necessarily the stigma or the bias against addicts with life threatening conditions (compounded by life threatening addictions) causing these patients to be particularly risky (or counter-productive) to treat - it's an especially tricky area of medicine compounded by a whole list of other factors that makes it difficult.

as for prescription heroin being just a dream - sadly, that may be the case in the USA at the moment, but it is done in some parts of the world.

hell, i would love for a doctor to be able to prescribe me cannabis for my sleep problems - it is truly the best medicine for my lifelong insomnia, but prescription cannabis seems like a fanciful dream for me as an Australian, given my country's political inaction on that front.
it really is a crazy fucked up - and very complicated - world we live in.

 

[zephyr]

Yes it can get expensive if the heart valves need replacing etc and long hospital stays. But if caught early its a simple antibiotic. But it could come back later even if they stop using. Its an evil bug thats normal on the skin.

But really when you think about it, a hospital stay shouldnt be as much as it is.

What needs doing is a general audit of hospitals and what makes things so expensive.

Doctors and hospitals can charge insurance companies anything they like. If course things get expensive for insurers.

Let me shed a tear for those poor poor insurers.


Then get the assessor and see what he/she would do if the patient was their mother/father/child.

How much is their life worth?


Addicts could go back to shooting again. Liver transplant patients could go back to drinking.

Bottom line us that if you get endocarditis yes you need treatment and its sick how an insurance company decides if you're worth their expense or not.


The USA have really got it wrong.

 

[spacejunk]

Bottom line us that if you get endocarditis yes you need treatment and its sick how an insurance company decides if you're worth their expense or not.

indeed. it's hard to understand how the world's richest nation can spend trillions of dollars on military and law enforcement but not on covering the costs of poor or uninsured people needing to go to hospital.

 

[zephyr]

The question I was hoping might be addressed is "Would IV drug users be more or less likely to go for treatment for endocarditis (or abscesses, etc.) if referral to an addiction specialist was part of the deal?"

Likely it could work. Fucking up your heart might be the incentive to get off drugs in itself and treatment should include options for that or follow up appointments.

Bu the fact that Ethics and COST of these treatments are in the same sentence is a worry.

Charging insurers half a million is ridiculous. Surgeries are about a tenth of that cost.


Thats the real problem.

Fund surgeons and health workers who are not gougers and are in it to help people. Surely there are some public services available?

 

[cduggles]

Right now America is headed toward even less and worse health care coverage, which is an awful thought. This is due in large part to the deeply entrenched political lobbies of the health insurance and pharmaceutical companies.

Unfortunately, everything that is happening in US medicine is also incentivizing good doctors to retire and subpar doctors to stay. So quality of care will also decline.

However, addiction is an issue that is getting attention and funding (sorry but it's practical), so I'm interested in thinking about what would work in terms of continuity of care for addicts beyond a patch-up to the extent that it is possible and effective.

The reason for this is that ethically, it's clear that clinicians must create a component of health care that addresses addiction, not just its physical manifestations. I just don't know what that looks like...