Infections from drugs force ethical decisions
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.”
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. “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 Pollard. He has seen an explosion of endocarditis cases, particularly among poor, young drug users whose hearts usually can be salvaged, but whose addiction goes unaddressed by a medical system that rarely takes responsibility for treating it.
Certain cases haunt him. A little more than a year ago, he replaced a heart valve in a 25-yearold 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. 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.
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.
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.
Prescribing rates for opioids are still strikingly high, and the overdose death rate in Roane County, where Whitefield lives, is three times the national average.
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 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 been proven 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 Whitefield, also need intricate surgery to repair or replace damaged heart valves. The cost can easily top $150,000, Pollard said.
Advice from specialty groups, such as 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 Pollard’s partners and who operated on Whitefield at Methodist Medical Center of Oak Ridge.
Their practice, owned by Covenant Health, will almost always operate on someone with a firsttime case of endocarditis from injecting drugs, 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.”
Pollard 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.”
Whitefield arrived at Methodist Medical Center with fullblown
“Everybody has sympathy for babies and children. No one wants to help the adult drug addict because the thought is they did this to themselves.”
— DR. THOMAS POLLARD, VETERAN CARDIOTHORACIC SURGEON IN KNOXVILLE
sepsis, floating in and out of consciousness. Her organs had started to shut down.
Martinez felt strongly about taking 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.
“To me, it seemed she had that social support that patients need once they recover from this,” he said.
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.
Whitefield has had occasional cravings since the surgery but says she has not used drugs again, traumatized by the memory of her ordeal.
The task force included people from each hospital system — Pollard’s, Covenant Health; the University of Tennessee Medical Center; and Tennova Healthcare — as well as from two drug treatment centers and some community groups.
The group discussed 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.
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 Pollard hopes government and private funding would help cover if the program expanded.
By spring, Pollard said, he was close to persuading Covenant Health to pay for five initial endocarditis patients to get addiction treatment after their hospital stays — if its competitors did the same. But Browne, Covenant’s chief medical officer, was noncommital in a written statement, saying that “due to the high cost of residential and outpatient treatment, no commitments have been made to proceed.”
Dr. Jerry Epps, chief medical officer at UT Medical Center, said in an interview that the proposal was “a big ask,” adding, “The hospitals are already paying a huge part of the financial burden for this patient population.”
Pollard will not see his project to completion. With the last of their children off to college, he and his wife have decided to move home to San Antonio, where he has mentioned his idea to his new practice.
“In some ways I’m disappointed,” he said of the lack of movement. “But it’s been forward progress, and I do think something will happen, probably this year.”
One recent morning, Whitefield waited anxiously to see her cardiologist, Dr. Larry Justice, about the results of some tests from the previous month.
She was worried, too, about the hepatitis C — another rampant problem among people who inject drugs — she had not been able to treat.
“I don’t have a primary care doctor,” Whitefield said. “Nobody will see me because of my drug use history.”
Justice arrived with good news: There was no evidence of endocarditis in her blood, and her repaired mitral valve looked good. But another result was troubling.
“One of your other valves is leaking a fair amount,” Justice said, and added: “I can’t guarantee you won’t need another valve surgery.”
She would not be denied a second surgery under these circumstances. But she desperately feared the prospect.
Justice had referred her to a gastrointestinal specialist so she could finally see about treating her hepatitis. She had not had a craving for weeks.
“I’m trying to think of ways to get myself more hope here,” she said.