Current Opioid Epidemic in the U.S.

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1 Link Between the Opioid Epidemic and Infective Endocarditis Aman J. Pathak, MD Attending Physician, Infectious Diseases New Hanover Regional Medical Center Associate Clinical Professor, UNC Chapel Hill School of Medicine Current Opioid Epidemic in the U.S. Drug overdose deaths and opioid involved have exploded in the last 15 years* Prescription opioids and heroin have led to a quadruple increase in overdose deaths* From 2000 to 2015, more than 500,000 deaths attributed to overdoses* Prescription opioids have increased 4 fold from 1999 to 2010* * North Carolina Opioid Epidemic 12,000 overdose deaths from 1999 to 2016 which totals an 800% increase * Epidemic has worsened due to easy availability of cheap heroin and fentanyl * Unintentional opioid overdoses in N.C have roughly cost 1.3 billion * *ttps://files.nc.gov/ncdhhs/opioid%20plan%20fact%20sheet_final_6_27_17b.pdf 1

2 New Hanover Opioid Related Deaths 2005 compared to 2015* Mecklenburg County Wake County Guilford County Forsyth County 26 to 61 (967K) 35 to 62 (952K) 27 to 47 (501K) 13 to 53 (357K) New Hanover County 26 to 45 (220K) * county figures opioid crisis north carolina How is this epidemic connected to an Increase in Cardiovascular Infections? What is infective endocarditis? Infection involving the endocardial surface of the heart, usually heart valves or intracardiac device such as ICD/Pacemaker Pathological lesion is vegetation (composed of platelets/fibrin/bacteria/inflammatory cells) IVDA and Infective Endocarditis Basic Epidemiology Data is difficult to obtain IVDA related IE 6 % to 8% of hospitalizations in 2000 to 12% in 2013 Trend to younger patients, white>nonwhites, male = females In N.C. between 2010 and 2015, 12 fold increase noted* *Hospitalizations for Endocarditis and Associated Health Care Costs Among Persons with Diagnosed Drug Dependence N.C , MMWR 2017 Jun 2

3 Pathophysiology Endocardial injury is the first step Sterile platelet fibrin nidus then forms Bacteria attaches to platelet fibrin deposits Growth occurs within the matrix making it difficult for host mechanisms to control Seeding occurs distally vs transient bacteremia from a mucosal or skin source Gross View in the OR 3

4 Pathogenesis /Damage to Endothelium in a IVDA Injection of particulate matter (talc) Repetitive use Contamination of syringes IVDA carries higher risk of CA Staphylococcus Aureus Saliva as drug diluent /contaminated injection equipment Microbiology Staphylococcus Aureus (MRSA vs MSSE) Virulent factors for MRSA/MSSA Resistance is mediated by PBP 2a, encoded by the meca gene Allows organism to grow in presence of methicillin/beta lactam antibiotics HA MRSA (SCCmec type II) USA 100/200 CA MRSA (SCCmec type IV) USA 300/400 CA MRSA > PVL toxin IVDA cases are mainly CA MRSA 4

5 Diagnosis Fever almost universal (90 % ) Anorexia/weight loss/malaise Heart murmur (85%) + blood cultures + 2d echocardiography vs TEE Modified Duke s Criteria 5

6 Complications as presenting symptoms Cardiac (valvular incompetency/chf) Neurological (embolic stroke/ich/brain abscess) Septic Emboli (kidney/spleen/lungs) Metastatic Infection (vertebral OM/septic arthritis/psoas abscess) Systemic Immune Reaction (acute GN) 6

7 Treatment Prolonged Antibiotics (IV) over the course of 6 weeks is the typical main stay of treatment This is tailored to specific organism found in blood culture data This in general requires constant vigilance/ oversight and dedicated central line access 7

8 Role of surgery CHF Paravalvular infection Conduction delay Persistent Blood Cultures Vegetation Size (> 1 cm) Major Embolus Organism itself (MRSA/ Yeast/ Pseudomonas) Pitfalls of Surgery in IVDA Poorer outcomes (one study showed 60% mortality at mean follow up of 13 months) Higher rates of post operative complications (i.e. PNA/ ARF/ Sepsis/ Emboli) Persistent drug use after surgery leading to higher rates of readmission and reinfection Challenges with Hospitalization The IVDA presents unique barriers to adequate treatment Unwilling to be hospitalized for long periods C/I to PICC lines and OPAT Noncompliance Withdrawing to opiates with weening Burn out among health care providers Institutional Financial Costs 8

9 Working Solutions? Acknowledgement at the state and national level is the first step North Carolina's Opioid Action Plan Coordinating the state s infrastructure to tackle the opioid crisis. Reducing the oversupply of prescription opioids. Reducing the diversion of prescription drugs and the flow of illicit drugs. Increasing community awareness and prevention. Making naloxone widely available. Expanding treatment and recovery systems of care. Measuring the effectiveness of these strategies based on results. A Possible Approach A comprehensive transitional care program Consisting of physicians / legal counsel / case management Likelihood of outpatient compliance * Risk Assessment of PICC * Commitment for addiction treatment * Alternative routes of management options* * C. R Libertin. The cost of recalcitrant IV drug user with serial cases of endocarditis A More Radical Approach? Accept that IVDA s are going to use drugs Institutional detox likely will not work leading to increased risk of OD in week after release Concept of Harm Reduction... supervised injection sites 24/7 needle exchange in the ER 9

10 Vancouver, B.C. s approach Community Transitional Care Team Significant community nursing outreach Issued rooms for IVDAs for with washrooms/kitchen for stability Encouraged to use safe injection sites to inject rather than their picc line In Summary A significant opioid crisis is among us Infectious complications will likely remain steady for the foreseeable future Hospitals and the communities they serve will need to adapt and innovate to serve the needs of this particular population 10