Article

Harm Reduction for Injection Drug Users with Infective Endocarditis: A Systematic Review

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Abstract

Background: Infective endocarditis in the setting of injection drug use (IDU-IE) can be managed medically and surgically, but the greatest risk to short-term survival are complications of continued use. Despite this, harm reduction interventions have not been widely adopted in inpatient settings for individuals with IDU-IE. Objectives: The aim of this systematic review was to determine the types, effectiveness, and availability of targeted harm reduction interventions for individuals with IDU-IE. In this review, harm reduction was defined as any practice aimed at reducing negative consequences associated with substance use. Methods: In accordance with the preferred reporting items for systematic reviews and meta-analyses (PRISMA) Guidelines, 5 electronic databases were systematically searched to identify studies targeting harm reduction interventions for individuals with IDU-IE. Study quality was appraised using the Cochrane Risk of Bias Tool. Key findings of studies were summarized descriptively as a quantitative meta-analysis could not be undertaken. Results: Four studies (involving 221 participants) met eligibility criteria. The mean age was 39.3 ± 16.7 years, 69.8% were males and 80.7% had an opioid use disorder. Harm reduction interventions included inpatient addictions consultations, needle hygiene interventions, and outpatient parenteral antibiotic therapy. Such interventions were associated with decreased morbidity and mortality for individuals with IDU-IE: 19% of patients receiving inpatient addictions consultation subsequently accepted residential treatment, 38% engaged in follow-up, and monthly illicit opioid use was lowered from 16.5 days to 1.5 days. Six-month mortality was 7.1%. Of the patients who received outpatient parenteral antibiotics, 93% did not experience any recurrent infections during follow-up and there were no patient deaths. Needle hygiene interventions reduced the rate of bacterial infections over a 6-month follow-up period (hazard ratio: 0.80; 95% confidence interval, 0.37–1.74). Conclusion: Harm reduction interventions are potentially effective means for reducing morbidity and mortality in patients with IDU-IE.

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... Full texts of the remaining 94 papers and of the additional three papers found by searching bibliographies were screened for eligibility, and 85 papers that were non-relevant or did not meet the eligibility criteria were removed. Twelve SRs were eligible (25)(26)(27)(28)(29)(30)(31)(32)(33)(34)(35)(36). Appendix 3 provides a list of the excluded full-text papers with the description of the reasons for exclusion (ordered by most to least common). ...
... As reflected in the Citation Matrix ( Table 2), among the eligible SRs, twenty primary studies were overlapping and 64 were included only in one SR. In six SRs, the use of opioids was confirmed in all primary studies relevant to our review question (25,26,30,(32)(33)(34)(35)(36). In the other five SRs (27-29, 31, 35), use of opioids was confirmed in 73-88% of relevant primary studies. ...
... Overall, we identified 8 different types of preventive interventions (Figure 2). Eleven studies (25-36) evaluated opioid substitution therapy (OST) and needle and syringe exchange programs (NSP) to prevent HCV and/or HIV along with several other interventions, and one SR evaluated interventions to prevent infectious endocarditis (25). All included SRs targeted persons who inject drugs, recruited in different settings ( Tables 3, 4). ...
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Background The North American opioid crisis is marked by high opioid-related mortality and morbidity, including opioid use-associated infections (OUAIs). Users of pharmaceutical and non-pharmaceutical opioids are at an increased risk of acquiring hepatitis C (HCV), human immunodeficiency virus (HIV), and other infections. No high-level evidence, however, has been synthesized regarding effectiveness of interventions to prevent OUAIs in legal, and illegal/mixed opioid users. The aim of the study is to synthesize available systematic review (SR)–level evidence on the scope and effectiveness of interventions to prevent OUAIs among opioid users. Methods A SR of SRs approach was applied. We searched PubMed, Embase, PsycINFO, Cochrane Database of Systematic Reviews, Epistemonikos and Google Scholar from inception to September 2020. Data selection and extraction were performed independently by three researchers. Risk of bias and quality of evidence were assessed using the AMSTAR2 tool. Results were narratively synthesized. Strength of evidence for each category was reported. Results Eleven of twelve identified SRs included interventions to prevent HCV/HIV transmission in persons who inject drugs (PWID), including opioids. One SR evaluated interventions to prevent recurrent infectious endocarditis. There was sufficient and tentative SR of SRs-level evidence for the effectiveness of opioid substitution therapy (OST) in preventing HIV and HCV, respectively. We found tentative evidence to support effectiveness of needle/syringe exchange programs (NSP) in HIV prevention, and sufficient evidence to support effectiveness of the combined OST and NSP in HCV prevention. There was insufficient SR-level evidence to support or discount effectiveness of other interventions to prevent OUAIs. No SR focused on non-PWID populations. Conclusion SR-level evidence supports the use of OST, NSP, and combined interventions for the reduction of HCV and HIV transmission in PWID. More research on prevention of other OUAIs and on prevention of OUAIs in non-PWID populations is urgently needed. Systematic Review Registration Registered in PROSPERO on July 30, 2020. https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=195929 , identifier: #195929.
... Hospitalization for IDU-IE is a "reachable moment" to effectively engage patients in addiction treatment and harm reduction care, including opioid agonist treatment (OAT; e.g. methadone, buprenorphine) and access to sterile drug injecting equipment [7][8][9][10][11]. OAT is associated with large reductions in all-cause mortality among patients with IDU-IE [12] and may be associated with reduced risk of IDU-IE recurrence [13][14][15][16]. ...
... Unfortunately, despite these standards of care and convincing evidence of their effectiveness, hospital care for patients with IDU-IE often focuses on management of the infection and its sequelae without addressing the underlying substance use disorder [19,23,32,36,38,39]. Our findings of poor access to OAT at the hospital in Halifax are consistent with several other studies from North American hospitals [9]. Among 37 patients admitted to a Maine hospital for IDU-IE who were not on OAT, five (19%) initiated OAT in hospital [40]. ...
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Background Addiction treatment and harm reduction services reduce risks of death and re-infection among patients with injection drug use-associated infective endocarditis (IDU-IE), but these are not offered at many hospitals. Among hospitalized patients with IDU-IE at the two tertiary-care hospitals in the Canadian Maritimes, we aimed to identify (1) the availability of opioid agonist treatment (OAT) and sterile drug injecting equipment, and (2) indicators of potential unmet addiction care needs. Methods Retrospective review of IDU-IE hospitalizations at Queen Elizabeth II Health Sciences Centre (Halifax, Nova Scotia) and the Saint John Regional Hospital (Saint John, New Brunswick), October 2015 -March 2017. In Halifax, there are no addiction medicine providers on staff; in Saint John, infectious diseases physicians also practice addiction medicine. Inclusion criteria were: (1) probable or definite IE as defined by the modified Duke criteria; and (2) injection drug use within the prior 3 months. Results We identified 38 hospitalizations (21 in Halifax and 17 in Saint John), for 30 unique patients. Among patients with IDU-IE and untreated opioid use disorder, OAT was offered to 36% (5/14) of patients in Halifax and 100% (6/6) of patients in Saint John. Once it was offered, most patients at both sites initiated OAT and planned to continue it after discharge. In Halifax, no patients were offered sterile injecting equipment, and during five hospitalizations staff confiscated patients’ own equipment. In Saint John, four patients were offered (and one was provided) injecting equipment in hospital, and during two hospitalizations staff confiscated patients’ own equipment. Concerns regarding undertreated pain or opioid withdrawal were documented during 66% (25/38) of hospitalizations, and in-hospital illicit or non-medical drug use during 32% (12/38). Two patients at each site (11%; 4/38) had self-directed discharges against medical advice. Conclusions Patients with IDU-IE in the Canadian Maritimes have unequal access to evidence-based addiction care depending on where they are hospitalized, which differs from the community-based standard of care. Indicators of potential unmet addiction care needs in hospital were common.
... There is evidence that concurrent disorder models are beneficial when considering the medical complications of SUDs, such as infective endocarditis in the setting of injection drug use. [14][15][16] To maintain continuity of care, we must ensure access to concurrent disorder consult services and champions in all settings, including inpatient and outpatient spheres, as well as in specialty psychiatry clinics and shared care services to ensure that the approach initiated in 1 domain is translated to the next domain, thereby avoiding conflicting paradigms In this regard, we must pair inpatient treatment needs with community services to maximize the value of therapy started during the index hospitalization. 17 Concurrent disorder consult models have an active role to play in outpatient settings as well. ...
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Despite increased awareness of the prevalence and burden of substance use disorders, there is limited access to addiction treatment services in Canada, including in psychiatric settings. While substance use disorders are highly comorbid and confer a poorer prognosis on psychiatric illnesses, psychiatric services are often ill-equipped in managing comorbid addictions. While there has slowly been an increase in recognition of this deficit in psychiatric training, there continues to be a deficit in concurrent disorder services in psychiatric care. A potential strategy to address this gap in clinical services is a concurrent disorder consult model. Herein, we outline a model for improved access to addiction treatment in psychiatric care and outline considerations for developing concurrent disorder consult services.
... As missing even a single dosage at the time of lockdown could lead to relapse, 29 continued access to OAT during the pandemic is a critical public health priority, 40,42,44,59 particularly for individuals with medical morbidities, such as endocarditis. [60][61][62] Primary care providers can support OUD exacerbation by COVID-19 by providing physically distanced office visits for OAT treatment. 63 Several agencies have already advocated for increased access to OAT during the pandemic. ...
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Background: Persons who use drugs (PWUD) are facing an epidemic during the global COVID-19 pandemic. In recent months, many medical institutions have released guidance documents to inform the management of PWUD as it pertains to COVID-19. Given the flurry of increasing guidance documents, we sought to synthesize the recommendations and identify consensus strategies to support PWUD during the pandemic. Aim: To review existing COVID-19 guidelines for PWUD to synthesize evidence and identify consensus and disagreement areas. Methods: We rapidly reviewed the grey literature (documents produced by organizations, including reports, working papers, government documents, white papers, and clinical guidelines) and published peer- reviewed articles using the World Health Organization guidelines. We organized recommendations by the substance use disorder considered (eg, opioid, stimulant, and alcohol), recommendation type (eg, pharmacothera- py and psychosocial), nature (eg, harm-reduction and abstinence), and score the responsibility (eg, physicians and allied health practitioners). Results: We identified 85 representative articles span- ning alcohol, opioid, tobacco, stimulant, and cannabis use disorders. Most reports involved opioid use disorder, generated by Canadian institutions, such as the British Columbia Centre for Substance Use, the Canadian Centre for Substance Use and Addiction, and the Canadian Research Initiative in Substance Misuse. An overview of the problem typically prefaced guideline documents (eg, increasing numbers of opioid overdose deaths), followed by a structured approach to management (eg, addressing intoxication and withdrawal) using multiple forms of interventions (eg, harm-reduction, pharmacotherapy, and psychosocial services). Across guidelines, there was consensus regarding the importance of maintaining access to evidence-based treatment through various creative means, such as virtual platforms, take-home medications, and home delivery services. However, there was controversy regarding safe-supply, supervised con- sumption sites, and alcohol retailers’ designation as “essential services” during the pandemic. Conclusions: With these challenges and insights in mind, the critical issue facing PWUD and their providers during the pandemic is maintaining access to evidence- based treatment and securing food, housing, and income. Along those lines, appropriate care should continue to be patient-centred, collaborative, and mindful of resources. Above all, we must continue to consider a biopsychosocial framework while providing evidence-based care. While these recommendations are helpful, we must apply our clinical judgment individually to weigh the risks and benefits to the patient and the public and destigmatize PWUD.
... We organized study findings into tables according to the PICOS framework (Methley et al., 2014). Our review's methods were consistent with previous narrative reviews with addiction themes (Bahji, 2019;Bahji et al., 2020;Bahji andBajaj, 2018, 2019;Bahji and Mazhar, 2016;Bahji and Stephenson, 2019). ...
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Using our research findings, we explore Harm Reduction and Methadone Maintenance Treatment (MMT) using an intersectional lens to provide a more complex understanding of Harm Reduction and MMT, particularly how Harm Reduction and MMT are experienced differently by people dependent on how they are positioned. Using the lens of intersectionality, we refine the notion of Harm Reduction by specifying the conditions in which both harm and benefit arise and how experiences of harm are continuous with wider experiences of domination and oppression; A qualitative design that uses ethnographic methods of in-depth individual and focus group interviews and naturalistic observation was conducted in a large city in Canada. Participants included Aboriginal clients accessing mainstream mental health and addictions care and primary health care settings and healthcare providers; All client-participants had profound histories of abuse and violence, most often connected to the legacy of colonialism (e.g., residential schooling) and ongoing colonial practices (e.g., stigma & everyday racism). Participants lived with co-occurring illness (e.g., HIV/AIDS, Hepatitis C, PTSD, depression, diabetes and substance use) and most lived in poverty. Many participants expressed mistrust with the healthcare system due to everyday experiences both within and outside the system that further marginalize them. In this paper, we focus on three intersecting issues that impact access to MMT: stigma and prejudice, social and structural constraints influencing enactment of peoples' agency, and homelessness; Harm reduction must move beyond a narrow concern with the harms directly related to drugs and drug use practices to address the harms associated with the determinants of drug use and drug and health policy. An intersectional lens elucidates the need for harm reduction approaches that reflect an understanding of and commitment to addressing the historical, socio-cultural and political forces that shape responses to mental illness/health, addictions, including harm reduction and methadone maintenance treatment.
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Many opioid-dependent patients do not receive care for addiction issues when hospitalized for other medical problems. Based on 3 years of clinical practice, we report the Transitional Opioid Program (TOP) experience using hospitalization as a "reachable moment" to identify and link opioid-dependent persons to addiction treatment from medical care. A program nurse identified, assessed, and enrolled hospitalized, out-of-treatment opioid-dependent drug users based on their receipt of methadone during hospitalization. At discharge, patients transitioned to an outpatient interim opioid agonist program providing 30-day stabilization followed by 60-day taper. The nurse provided case management emphasizing HIV risk reduction, health education, counseling, and medical follow-up. Treatment outcomes included opioid agonist stabilization then taper or transfer to long-term opioid agonist treatment. From January 2002 to January 2005, 362 unique hospitalized, opioid-dependent drug users were screened; 56% (n = 203) met eligibility criteria and enrolled into the program. Subsequently, 82% (167/203) presented to the program clinic post-hospital discharge; for 59% (119/203) treatment was provided, for 26% (52/203) treatment was not provided, and for 16% (32/203) treatment was not possible (pursuit of TOP objectives precluded by medical problems, psychiatric issues, or incarceration). Program patients adhered to a spectrum of medical recommendations (e.g., obtaining prescription medications, medical follow-up). The Transitional Opioid Program (TOP) identified at-risk hospitalized, out-of-treatment opioid-dependent drug users and, by offering a range of treatment intensity options, engaged a majority into addiction treatment. Hospitalization can be a "reachable moment" to engage and link drug users into addiction treatment.
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Within the UK and in many other countries two of the most significant issues with regard to the development of health and social care services for drug users has been the growth of the consumer perspective and the philosophy of harm reduction. In this paper we look at drug users' aspirations from treatment and consider whether drug users are looking to treatment to reduce their risk behaviour or to become abstinent from their drug use. The paper is based on interviews using a core schedule with 1007 drug users starting a new episode of drug treatment in Scotland. Participants were recruited from a total of 33 drug treatment agencies located in rural, urban and inner-city areas across Scotland. Our research has identified widespread support for abstinence as a goal of treatment with 56.6% of drug users questioned identifying 'abstinence' as the only change they hoped to achieve on the basis of attending the drug treatment agency. By contrast relatively small proportions of drug users questioned identified harm reduction changes in terms of their aspiration from treatment, 7.1% cited 'reduced drug use', and 7.4% cited 'stabilization' only. Less than 1% of respondents identified 'safer drug use' or 'another goal', whilst just over 4% reported having 'no goals'. The prioritization of abstinence over harm reduction in drug users treatment aspirations was consistent across treatment setting (prison, residential and community) gender, treatment type (with the exception of those receiving methadone) and severity of dependence. On the basis of these results there would appear to be a need for harm reduction services to be assiduous in explaining to clients the reason for their focus and for ensuring that drug users have access to an array of services encompassing those that stress a harm reduction focus and those that are more oriented towards abstinence.
Article
Introduction Canada is experiencing a new era of harm reduction policymaking and investment. While many provinces and territories are expanding access to these services, harm reduction policy and policymaking varies across the country. The present study, part of the Canadian Harm Reduction Policy Project (CHARPP), described policy actors’ views on formal harm reduction policies in Canada’s 13 provinces and territories. Methods As part of CHARPP’s mixed-method, multiple case study, we conducted qualitative interviews with 75 policy actors, including government officials, health system leaders, senior staff at community organizations, and advocates with self-identified lived experience of using drugs. Interviews were conducted in English or French, and recorded and transcribed verbatim. We used latent content analysis to inductively code the data and generate main findings. NVivo 11 was used to organize the transcripts. Results Participants expressed divergent views on formal provincial/territorial policies and their impact on availability of harm reduction programs and services. While some identified a need to develop new policies or improve existing ones, others resisted bureaucratization of harm reduction or felt the absence of formal policy was instead, advantageous. Instances where harm reduction was advanced outside of formal policymaking were also described. Discussion Previous CHARPP research documented wide variability in quantity and quality of formal harm reduction policies across Canada, and characterized official policy documents as serving largely rhetorical rather than instrumental functions. The present findings highlight diverse ways that actors used their discretion to navigate these weak policy contexts. Participants’ views and experiences sometimes referred to strengthening policy support, but institutionalization of harm reduction was also resisted or rejected. Results suggest that actors adopt a range of pragmatic strategies to advance harm reduction services in response to policy vacuums characteristic of morality policy domains, and challenge assumptions about the utility of formal policies for advancing harm reduction. Keywords Harm reductionPolicymakingCanadaOpioid crisisQualitative researchKey informant interviews
Article
In Reply In discussing the topic of injection drug use–associated infective endocarditis in our review,¹ our intent was to highlight the lack of certainty with respect to the use of surgery and outcomes in these patients. Cardiac surgery in patients with injection drug use–associated infective endocarditis has been associated with higher mortality and reoperation in the first 6 months after surgery than in patients with infective endocarditis not related to injection drug use.² Surgical decision-making about infective endocarditis is complicated in general. For example, approximately 1 in 4 patients with infective endocarditis (regardless of whether they use intravenous drugs) with indications for surgery do not receive surgery as part of their management, particularly those with infective endocarditis due to Staphylococcus aureus.³ An important and challenging aspect of managing infective endocarditis is addressing host factors that impede the use of surgery when indications are present. With injection drug use–associated infective endocarditis, the risks of ongoing addiction, injection drug use, and infection relapse or recurrence adds greater complexity that needs to be addressed. We agree that addiction treatment is a crucial aspect of care for patients with injection drug use–associated infective endocarditis and is often suboptimally addressed.⁴ Also, we regret if readers perceived any unintended negativity or judgment with respect to the terminology used in our brief discussion of injection drug use–associated infective endocarditis.
Article
Importance Infective endocarditis occurs in approximately 15 of 100 000 people in the United States and has increased in incidence. Clinicians must make treatment decisions with respect to prophylaxis, surgical management, specific antibiotics, and the length of treatment in the setting of emerging, sometimes inconclusive clinical research findings. Observations Community–associated infective endocarditis remains the predominant form of the disease; however, health care accounts for one-third of cases in high-income countries. As medical interventions are increasingly performed on older patients, the disease incidence from cardiac implanted electronic devices is also increasing. In addition, younger patients involved with intravenous drug use has increased in the past decade and with it the proportion of US hospitalization has increased to more than 10%. These epidemiological factors have led to Staphylococcus aureus being the most common cause in high-income countries, accounting for up to 40% of cases. The mainstays of diagnosis are still echocardiography and blood cultures. Adjunctive imaging such as cardiac computed tomographic and nuclear imaging can improve the sensitivity for diagnosis when echocardiography is not conclusive. Serological studies, histopathology, and polymerase chain reaction assays have distinct roles in the diagnosis of infective endocarditis when blood culture have tested negative with the highest yield obtained from serological studies. Increasing antibiotic resistance, particularly to S aureus, has led to a need for different antibiotic treatment options such as newer antibiotics and combination therapy regimens. Surgery can confer a survival benefit to patients with major complications; however, the decision to pursue surgery must balance the risks and benefits of operations in these frequently high-risk patients. Conclusions and Relevance The epidemiology and management of infective endocarditis are continually changing. Guidelines provide specific recommendations about management; however, careful attention to individual patient characteristics, pathogen, and risk of sequela must be considered when making therapeutic decisions.
Article
: In this issue of the Journal of Addiction Medicine, 2 studies fill an important gap in knowledge by examining predictors of leaving against medical advice from inpatient withdrawal management settings. The studies identify important risk factors for leaving against medical advice and highlight important areas for inpatient withdrawal management. These include the use of substance specific standardized protocols and initiation of opioid agonist treatment instead of opioid detoxification given harms associated with opioid withdrawal. Further need for increased training in addiction medicine for primary care physicians, and use of inpatient addiction medicine consult services as part of early intervention for substance withdrawal are also discussed.
Article
Objective: To conduct a pilot needs assessment of underlying substance use disorders (SUD), motivation for SUD treatment, and willingness to enter residential SUD treatment in hospitalized adults who inject drugs with complex infections requiring intravenous (IV) antibiotics, and to assess the presence of in-hospital illicit substance use. Patients and methods: From March 8, 2016 through August 25, 2016 hospitalized, English-speaking, adult patients not currently in SUD treatment with a history of injection drug use and a current infection requiring treatment with IV antibiotics, were prospectively enrolled. Participants were followed weekly during the hospitalization and for 60 days after discharge via interview and medical record review. Results: Of the 42 participants, 8 (19.0%) accepted discharge to residential SUD treatment, 16 (38.0%) completed at least one follow-up research visit after hospital discharge, and 3 (7.1%) died during the 5-month study period. The majority (33; 78%) were hospitalized with endocarditis, and 37 (88.0%) had an opioid use disorder (DSM-5). Mean days of self-reported IV opioid use in the 30 days before hospitalization compared to 30 days after discharge decreased significantly (16.5 to 1.5, P = .001) despite not receiving SUD treatment. Illicit in-hospital drug use was identified in 17 (40.5%) participants, with opioids most commonly detected. Conclusion: Hospitalization is a 'reachable moment' and critical opportunity to initiate evidence-based treatment for opioid use disorder. The ongoing in-hospital illicit drug use and high short-term mortality observed in this study contribute to the mandate to expand access to effective pharmacotherapy for opioid use disorder and integrate it into health care settings.
Article
Backgrounds: Georgia faces high HCV rates (5.4% of chronic cases in general population) with an epidemic concentrated among people who inject drugs (PWID). A National HCV Elimination Program (NHCEP), was launched in April 2015, aiming to eliminate HCV by 2020. To succeed, this program must develop tailored interventions to enroll PWID in treatment. Intervention: We implemented a pilot intervention to facilitate access to and retention of PWID in the NHCEP, and to prevent reinfection after treatment. Screening was offered at a harm reduction center. PWID with positive results were followed by peer-workers during medical assessment, which lasted 73days in average, and throughout the treatment by Sofosbuvir and Ribavirin+/- PegInterferon for 12, 24 or 48 weeks delivered at a medical center. Additional prevention sessions and PCR checks were delivered to PWID 6 and 12 months after the confirmation of sustained virologic response. Results: The pilot intervention screened 554 people in 5 months with 244 starting treatment. The majority of participants (98.0%, n=239) completed the treatment. The intervention, initially implemented in the capital, was replicated in a rural area. Conclusion: Peer-supported and strongly integrated, comprehensive HCV care will help PWID reach high uptake and adherence to care.
Article
A young adult with severe opioid use disorder (OUD) secondary to long-standing intravenous (IV) heroin use was admitted to the hospital with encephalopathy, respiratory failure, and septic shock. Two sets of blood cultures were positive for methicillin-sensitive Staphylococcus aureus, as were cultures of his cerebrospinal fluid. He was found to have mitral valve infective endocarditis with a subannular abscess, acute mitral regurgitation, and septic cerebral emboli. He underwent mitral valve replacement and placement of a pericardial patch. During the hospitalization he was diagnosed as having chronic hepatitis C virus infection, which he most likely contracted from sharing needles. Six weeks of appropriate antibiotics were completed outside of the hospital through a peripherally inserted central catheter (PICC) under the supervision of a family member. During this hospitalization, no treatment for OUD was offered or initiated.
Article
U.S. hospitalizations for severe infections associated with illicit opioid use have doubled over the past decade and are often prolonged and resource-intensive, but medication-assisted treatment for opioid use disorder can be integrated into hospital care.
Article
This JAMA Clinical Guidelines Synopsis summarizes the British Columbia Ministry of Health’s 2015 guidelines on clinical management of opioid use disorder in adults. Box Section Ref ID Guideline title Guideline for the Clinical Management of Opioid Addiction Developer Vancouver Coastal Health, Providence Health Care, and Ministry of Health, British Columbia, Canada Release date November 2015 Funding source Funded publicly through governmental grants Target population Nonpregnant adult patients with opioid use disorder Major recommendations • Opioid withdrawal alone is not recommended for treatment of opioid use disorder in most patients because of increased risks of overdose death and infectious disease, particularly HIV through intravenous drug use, following detoxification (moderate-quality evidence; strong recommendation). • In the absence of contraindications, medically supervised opioid agonist treatment should be offered to patients. Buprenorphine/naloxone is the preferred first-line treatment. Methadone is an alternative in certain patient populations (high-quality evidence; strong recommendation). • Psychosocial supports tailored to patient needs may be offered as an adjunct to medical treatment (moderate-quality evidence; conditional recommendation).
Article
Background and objectives: A feared complication of opioid use disorder (OUD) is intravenous drug use related infective endocarditis (IDU-IE). We report on our experience engaging hospitalized IDU-IE patients to initiate medication-assisted treatment (MAT). Methods: A retrospective study (n = 29) using descriptive statistics. Results: Overall, 9 (31.0%) successfully initiated buprenorphine maintenance during the hospitalization, and 9 (31.0%) accepted a referral to methadone maintenance following discharge. Eleven (37.9%) declined MAT altogether. Discussion and conclusions: Hospitalizations may represent an important opportunity to engage IDU-IE patients to initiate MAT. Scientific significance: The study provides preliminary support of engaging hospitalized IDU-IE patients to initiate MAT. (Am J Addict 2016;XX:1-4).
Article
Background: Infective endocarditis is a serious infection often resulting from injection drug use. Inpatient treatment regularly focuses on management of infection without attention to the underlying addiction. We aimed to determine the addiction interventions done in patients hospitalized with injection drug use associated infective endocarditis. Methods: This is a retrospective review of patients hospitalized with injection drug use associated infective endocarditis from January, 2004 through August, 2014 at a large academic tertiary care center in Boston, Massachusetts. For the initial and subsequent admissions, data was collected regarding addiction interventions, including consultation by social work, addiction clinical nurse and psychiatry, documentation of addiction in the discharge summary plan, plan for medication-assisted treatment and naloxone provision. Results: 102 patients were admitted with injection drug use associated infective endocarditis, 50 patients (49.0%) were readmitted and 28 (27.5%) patients had ongoing injection drug use at readmission. At initial admission, 86.4% of patients had social work consultation, 23.7% had addiction consultation, and 24.0% had psychiatry consultation. Addiction was mentioned in 55.9% of discharge summary plans, 7.8% of patients had a plan for medication-assisted treatment, and naloxone was never prescribed. Out of 102 patients, 26 (25.5%) are deceased. The median age at death was 40.9 years (IQR 28.7-48.7). Conclusions: We found that patients hospitalized with injection drug use associated infective endocarditis had high rates of readmission, recurrent infective endocarditis and death. Despite this, addictions interventions were suboptimal. Improved addiction interventions are imperative in the treatment of injection drug use associated infective endocarditis.
Deep tissue infection is a serious sequela that often demands intravenous (IV) antibiotic treatment. With respect to IV drug users (IDU’s), research and lived experience demonstrates a trend of failed treatment outcomes, most notably associated with leaving hospital against medical advice (LAMA) prior to treatment completion, increased adverse outcomes and patient hardship. This paper examines an alternative model for delivering and completing IV antibiotic treatment to IDU’s in a community care setting. A retrospective study was designed to review client characteristics. A total of 33 in-depth interviews were conducted with clients, clinicians and with staff. The impact of treatment adherence and completion, as well as client satisfaction of care was explored. A total of 165 patients were admitted during the study period. Osteomyelitis was the primary cause for IV antibiotics. Risk of leaving AMA was significantly lower for community model (p value
Article
Introduction and aims: People who inject drugs (PWID) engage in practices that put them at risk for various infections and overdose. The primary aim of this study was to examine common barriers to engaging in two risk reduction practices - cleaning one's skin at the injection site and always using new needles to inject - among heroin injectors in Denver, CO. Method: In 2010, 48 PWIDs were recruited through street outreach and completed a structured interview that included questions on the frequency of specific risk reduction practices (skin cleaning and using new needles) and barriers associated with these practices. Results: Though many of the reported barriers were similar across the two practices, the most common barriers associated with skin cleaning included being in withdrawal and not being prepared with materials prior to injection. Fear of being arrested and being in withdrawal were most frequently reported for using new needles. Multivariate and t-test analyses demonstrated that individuals who skin cleaned and used new needles more frequently reported less barriers to these practices. Conclusions: Participants reported a number of barriers to risk reduction, including those that are within the personal control of the injector, barriers that are consequences of addiction or psychological problems, and those that are structural or a function of the risk environment. Statistical analysis found that PWIDs who were more likely to skin clean and use new needles reported less barriers. Addressing barriers when intervening with PWID appears important to increase the success of risk reduction interventions.
Article
We tested the efficacy of a brief intervention based on motivational interviewing (MI) to reduce high-risk injection behaviours over a 6-month period among people who inject drugs (PWID). A single site 2-group parallel randomized controlled trial comparing MI with a brief educational intervention (EI). A study office located in downtown Montréal, Canada, close to the community-based harm reduction programs where PWID were recruited. PWID who had shared drug injection equipment or shared drugs by backloading or frontloading in the month prior to recruitment were randomized to either the MI (112) or EI (109) group. The MI aimed to 1) encourage PWID to voice their desires, needs and reasons to change behaviours; 2) boost motivation to change behaviours; and 3) when the person was ready, support the plan he or she chose to reduce injection risk behaviours. The EI consisted of an individual session about safe injection behaviours. The primary outcome was defined as having any of these risk behaviours at 6 months: having shared syringes, containers, filters or water to inject drugs in the previous month, and backloading/frontloading; each behaviour was examined separately, as secondary outcomes. The probability of reporting a risk injection behaviour decreased in both the MI and the EI groups. At 6-month follow-up, participants who reported any risk behaviours were 50% (OR = 0.50; CI:0.13-0.87) less likely to be in the MI group than in the EI group as well as those who reported sharing containers (OR = 0.50; CI:0.09-0.90). PWID who reported sharing equipment excluding syringes, were 53% less likely to be in the MI group (OR = 0.47; CI: 0.11-0.84). A brief motivational interviewing intervention was more effective than a brief educational intervention in reducing some high risk injecting behaviours up in the subsequent 6 months. This article is protected by copyright. All rights reserved. This article is protected by copyright. All rights reserved.
Article
Whilst it used to affect mostly intravenous drug users and patients who underwent valvular surgery with suboptimal infection control procedures, fungal endocarditis is now mostly observed in patients with severe immunodeficiency (onco-haematology), in association with chronic central venous access and broad-spectrum antibiotic use. The incidence of fungal endocarditis has probably decreased in most developed countries with access to harm-reduction policies (i.e. needle exchange programmes) and with improved infection control procedures during cardiac surgery. Use of specific blood culture bottles for diagnosis of fungal endocarditis has decreased due to optimisation of media and automated culture systems. Meanwhile, the advent of rapid techniques, including fungal antigen detection (galactomannan, mannan/anti-mannan antibodies and β-1,3-d-glucans) and PCR (e.g. universal fungal PCR targeting 18S rRNA genes), shall improve sensitivity and reduce diagnostics delays, although limited data are available on their use for the diagnosis of fungal endocarditis. New antifungal agents available since the early 2000s may represent dramatic improvement for fungal endocarditis: (i) a new class, the echinocandins, has the potential to improve the management of Candida endocarditis owing to its fungicidal effect on yeasts as well as tolerability of increased dosages; and (ii) improved survival in patients with invasive aspergillosis with voriconazole compared with amphotericin B, and this may apply to Aspergillus sp. endocarditis as well, although its prognosis remains dismal. These achievements may allow selected patients to be cured with prolonged medical treatment alone when surgery is considered too risky.
Article
Introduction and Aims: Increasing the frequency with which injecting drug users (IDUs) engage in self-initiated harm reduction strategies could improve their health, but few investigations have examined IDUs’ perceived barriers to engaging in these behaviors. Method: We interviewed 90 IDUs recruited from needle exchanges to assess: (a) perceived obstacles to their use of two specific harm reduction strategies (i.e., test shots and pre-injection skin cleaning) designed to reduce two unhealthy outcomes (i.e., overdose and bacterial infections, respectively) and (b) their use of other risk-reduction practices. Results: The most frequently cited barrier for both test shots and skin cleaning was being in a rush to inject one's drugs. Other, less commonly cited barriers were strategy-specific (e.g., buying drugs from a known dealer as a reason not to do a test shot; not having access to cleaning supplies as a reason not to clean skin). Regarding other risk reduction practices, participants most frequently reported using new or clean injecting supplies and avoiding sharing needles and injecting supplies. Discussion and Conclusions: Some, but not all, of the barriers generated by participants in our study were similar to those frequently reported in other investigations, perhaps due to differences in the type of sample recruited or in the harm reduction behaviors investigated.
Article
Bacterial infections are widespread problems among drug injectors, requiring novel preventive intervention. As part of a NIDA-funded study, we developed an intervention based on the Information-Motivation-Behavioral Skills model, past research, injection hygiene protocols, and data collected from focus groups with 32 injectors in Denver in 2009. Qualitative responses from focus groups indicated that most participants had experienced skin abscesses and believed that bacterial infections were commonly a result of drug cut, injecting intramuscularly, and reusing needles. Access to injection supplies and experiencing withdrawal were the most frequently reported barriers to utilizing risk reduction. Implications for intervention development are discussed.
Article
OBJECTIVE: To determine the feasibility of primary care-based ambulatory opioid detoxification (AOD) using two protocols: clonidine and clonidine plus naltrexone. SETTING: The Central Medical Unit (CMU)—a freestanding primary care medical clinic staffed by physicians and nurse practitioners. PATIENTS: Injection drug users (IDUs) seeking substance abuse treatment between the ages of 18 and 50 years who were addicted to opioids (e.g., heroin) and not currently in drug treatment. INTERVENTIONS: In the clonidine protocol, clonidine was administered every 4 hours “as needed” for up to 12 days. In the clonidine plus naltrexone protocol, clonidine was administered and naltrexone was administered in increasing doses over five days. Both protocols included “adjuvant” medications for muscle cramps, insomnia, and vomiting. Successfully detoxified patients were referred to ongoing drug treatment. DESIGN: A prospective nonrandomized clinical trial. MEASUREMENTS AND MAIN RESULTS: One hundred forty opioid-addicted IDUs were referred to the medical clinic for AOD. Among the 125 patients who enrolled in the study, 57 selected clonidine and 68 selected clonidine/naltrexone. The treatment groups (clonidine vs clonidine/naltrexone) were similar at baseline with respect to: age at first heroin use (21 years vs 23 years), mean admission opioid craving score (45/100 vs 49/100), and withdrawal symptom score (19/72 vs 18/72). Overall, 70% (88/125) of the AODs were successful, including 42% (24/57) for clonidine and 94% (64/68) for clonidine/naltrexone (p<0.001). CONCLUSIONS: This study suggests that primary care-based AOD can be safely and effectively carried out by primary care providers and that clonidine/naltrexone may be more effective in this setting than is clonidine alone. Ambulatory opioid detoxification can give internists a larger role in initiating drug treatment for IDUs who are addicted to opioids.
Article
Right-sided infective endocarditis (RSIE) accounts for 5-10% of all cases of infective endocarditis and is predominantly encountered among injecting drug users (IDUs). RSIE diagnosis requires a high index of suspicion as respiratory symptoms predominate. Prognosis of isolated RSIE is favourable, and most cases (70-80%) resolve following antibiotic administration. Surgical intervention is indicated in patients with persistent infection that does not respond to antibiotic therapy, recurrent pulmonary emboli, intractable heart failure and if the size of a vegetation increases or persists at >1 cm. Techniques can be divided into 'prosthetic' (valve replacement or prosthetic annular implantation) or 'non-prosthetic' ones (Kay's or De Vega's annuloplasty, bicuspidalization or valvectomy). In IDUs who run a high risk of complications, vegetectomy and valve repair, avoiding artificial material should be considered as the first line of surgical management as is associated with better late survival.
Article
We examined whether perceived susceptibility to and severity of two injection-related health conditions (i.e., non-fatal overdose and bacterial infections), and perceived benefits of, barriers to, self-efficacy to, social acceptance of, and recent use of two harm-reduction behaviors (i.e., injecting test shots and pre-injection skin cleaning), predicted injecting drug users' near-term intentions to engage in these two strategies. Recent past use of these two behaviors consistently and positively predicted near-term intentions in each of four drug-use situations (i.e., in withdrawal, not in withdrawal, alone, and with others). Perceived susceptibility to non-fatal overdose predicted intentions to do test shots, but only when participants imagined not being in withdrawal or injecting when alone. Perceived self-efficacy to clean one's skin predicted intentions to engage in this behavior, but only when participants imagined injecting while not in withdrawal. Participants' ratings of how often other injectors in their social network engage in pre-injection skin cleaning was also a significant positive predictor of intentions to clean one's skin, but only when they imagined being in withdrawal. Finally, length of time attending the needle exchange program was negatively associated with intention to engage in skin cleaning when not in withdrawal.
Article
The enrollment of intravenous drug users (IVDUs) into an outpatient parenteral antibiotic treatment (OPAT) service using a peripherally inserted central catheter (PICC) is controversial and often avoided. The National University Hospital in Singapore has a policy of permitting OPAT-based treatment of IVDU patients with appropriate medical indications. We report on our experiences. A prospective observational study was conducted on IVDU patients requiring parenteral antibiotics via an OPAT service from January 2005 to December 2009. Clinically appropriate patients were screened using pre-defined criteria and enrolled into our service, where standardized measures were enforced to prevent and detect PICC abuse and optimize treatment. Outcomes measured included mortality, completion of therapy, PICC abuse, and readmission for infective or treatment-related complications during OPAT and a 30 day follow-up period. Twenty-nine IVDU patients received treatment in our OPAT service (total 675 patient-days). The median duration of therapy was 18 days (range 1-85). Infective endocarditis was the primary diagnosis in 42% of cases. Two patients (7%) had recrudescent infection after absconding during their inpatient stay. These two patients subsequently completed treatment in OPAT. There were no deaths or cases of PICC abuse. Five patients (17%) during OPAT and one patient (3%) during the 30-day follow-up period required readmission for infective or treatment-related complications. Appropriately selected, counselled and monitored patients with a history of being an IVDU can be treated safely and successfully via OPAT centres. It is likely that some will respond better to treatment in an outpatient setting.
Article
Harm reduction is an umbrella term for interventions aiming to reduce the problematic effects of behaviors. Although harm reduction was originally and most frequently associated with substance use, it is increasingly being applied to a multitude of other behavioral disorders. This article reviews the state of empirical research on harm reduction practices including alcohol interventions for youth, college students, and a variety of other adult interventions. We also review nicotine replacement and opioid substitution, as well as needle exchanges and safe injection sites for intravenous drug users. Dozens of peer-reviewed controlled trial publications provide support for the effectiveness of harm reduction for a multitude of clients and disorders without indications of iatrogenic effects. Harm reduction interventions provide additional tools for clinicians working with clients who, for whatever reason, may not be ready, willing, or able to pursue full abstinence as a goal.
Article
There is great need to sustain harm reduction programmes for opiate-dependent persons, given variable retention of opioid agonist treatment (OAT) enrolees. Resource challenges may lead some health organizations to discontinue such programmes, though just as programmatic evaluation may determine efficacy and cost-effectiveness so to does it aid in examining impacts of programme dissolution. This retrospective evaluation investigated impacts of the dissolution of a 'Minimal Services' (MS) harm reduction programme for substance-abusing OAT clientele at an urban U.S. Veterans Affairs Medical Centre. Targeted clinical data concerning treatment retention, substance use and service utilization was abstracted from medical records of MS-assignees (N=32) and a matched comparison group of standard OAT enrolees. Chart reviewers gathered data for a two-year period encompassing baseline, transitional, and dissolution study phases. Relative to matched-controls, MS-assignees exhibited: (1) disproportionately poor treatment retention over the two-year period; (2) high and temporally stable rates of documented substance use across study phases, and (3) increased utilization of resource-laden VAMC services after MS dissolution. Collective results suggest MS programme dissolution was associated with adverse conditions for assignees and the larger treatment setting, and reinforce the need for pragmatic, humane treatment policies to facilitate retention of opiate-dependent persons.
Article
Six hundred patients from a Washington, D.C. population of 20,000 heroin addicts were admitted to D.C. General Hospital between November 1967 and April 1971. Bacterial endocarditis was found in 50 of them (8 per cent). The presenting features were fever (50 patients), pulmonary embolism (32 patients), positive blood cultures (39 patients), subcutaneous abscesses (2 patients), empyema (1 patient), septic arthritis (1 patient) and pericardial effusion (1 patient). The tricuspid valve alone was involved in 36 patients (72 per cent) and with other valves in 6 patients. Staphylococcus aureus was found in 28 patients, Streptococcus viridans in 4 and Streptococcus faecalis in 3. There was an over-all mortality rate of 28 per cent but pure right-sided lesions were found in only 16 per cent (6 of 38 patients). Attention to the auscultatory features of acute tricuspid regurgitation was the predominant factor leading to early diagnosis.
Article
To determine the feasibility of primary care-based ambulatory opioid detoxification (AOD) using two protocols: clonidine and clonidine plus naltrexone. The Central Medical Unit (CMU)--a freestanding primary care medical clinic staffed by physicians and nurse practitioners. Injection drug users (IDUs) seeking substance abuse treatment between the ages of 18 and 50 years who were addicted to opioids (e.g., heroin) and not currently in drug treatment. In the clonidine protocol, clonidine was administered every 4 hours "as needed" for up to 12 days. In the clonidine plus naltrexone protocol, clonidine was administered and naltrexone was administered in increasing doses over five days. Both protocols included "adjuvant" medications for muscle cramps, insomnia, and vomiting. Successfully detoxified patients were referred to ongoing drug treatment. A prospective nonrandomized clinical trial. One hundred forty opioid-addicted IDUs were referred to the medical clinic for AOD. Among the 125 patients who enrolled in the study, 57 selected clonidine and 68 selected clonidine/naltrexone. The treatment groups (clonidine vs clonidine/naltrexone) were similar at baseline with respect to: age at first heroin use (21 years vs 23 years), mean admission opioid craving score (45/100 vs 49/100), and withdrawal symptom score (19/72 vs 18/72). Overall, 70% (88/125) of the AODs were successful, including 42% (24/57) for clonidine and 94% (64/68) for clonidine/naltrexone (p < 0.001). This study suggests that primary care-based AOD can be safely and effectively carried out by primary care providers and that clonidine/naltrexone may be more effective in this setting than is clonidine alone. Ambulatory opioid detoxification can give internists a larger role in initiating drug treatment for IDUs who are addicted to opioids.
Article
Advantage was taken of a natural experiment to compare the outcome of abstinence-oriented and indefinite methadone maintenance. Subjects assigned to an abstinence-oriented program were significantly more likely than those assigned to indefinite maintenance to use heroin (OR 1.3) and amphetamines (OR 2.8) during the first 2 years of methadone treatment but less likely to use benzodiazepines (OR 0.7). Subjects discharged from the abstinence-oriented program were significantly more likely to relapse and return to maintenance treatment (RR, first 6 months, 4.2). The abstinence-oriented program was also less able to attract heroin addicts into maintenance treatment.
Article
Infections, in particular soft tissue infections (cellulitis, skin abscesses), are the leading cause for emergency department visits and hospital admissions of drug injection users (IDUs). Staphylococcus aureus is the most relevant bacterial pathogen in this population. It is the main cause of soft tissue infections and of severe infections such as endocarditis and bacteremia. Moreover, epidemic spread of methicillin-resistant S. aureus (MRSA) among IDUs has occurred in Europe and North America. Nasal carriage of S. aureus is associated with an increased risk of subsequent S. aureus infections, and it has been shown that active IDUs have a higher rate of colonization with S. aureus than the general population. However, it is still unknown why an individual carries S. aureus. In particular, repeated injections do not appear to be the main predisposing factor for S. aureus carriage. Infections associated with injection drug use are frequently the consequence of the illegal status of street drugs. Harm reduction programs, including needle exchange programs, safer injecting facilities and injection opiate substitution programs can reduce the incidence of infections among severely addicted IDUs.