Saving Addicts’ Hearts Poses a Dilemma for Physicians
who’s drinking a fifth of vodka on the stretcher.”
The problem has consumed Dr. Pollard, 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.
As cases have multiplied around the United States, 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 intravenous drug users survived for a decade without reinfection or other complications, compared with 41 percent of patients who were not IV drug users.
Dr. Pollard has been lobbying hospital systems in Knoxville to provide addiction treatment for willing endocarditis patients after their surgery. If the hospitals offered it, he reasons, doctors would have more justification for turning away patients who refused and 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.
Treatment for endocarditis usually involves up to six weeks of intravenous antibiotics. Many, like Ms. Whitefield, also need intricate surgery to repair or replace damaged heart valves. The cost can 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 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.
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.
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 or not they get heart surgery. 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.”
Ms. Whitefield 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 then from friends.
She and her high school boyfriend, Chris Bunch, had three children by the time she was 26. 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 started injecting crushed opioid pills and meth.
After sharing a needle with a brother in June 2016, Ms. Whitefield started shivering and sweating. A fever followed, and she lay for almost a week on the couch, thinking she had a kidney infection. She was delirious by the time her oldest son, Jayden, then 8, woke her stepfather one morning and told him to call 911.
She arrived at Methodist Medical Center of Oak Ridge with sepsis, floating in and out of consciousness. Her organs had started to shut down.
Her stepfather, Brian Mig-nogna, 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 at her bedside, and 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.”
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 stressed that the surgery would be “a one-time deal,” Mr. Mignogna recalled.
Two weeks later, Ms. Whitefield was well enough to go home. She soon began seeing a counselor at a clinic unaffiliated with the hospital system and taking buprenorphine, a medica- tion 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.”
One recent morning, Ms. Whitefield waited to see her cardiologist, Dr. Larry Justice, about the results of some tests from the previous month. On her chest, her thin pink surgery scar stretched from the V- neck of her shirt to her collarbone. She ticked off her latest problems to a nurse: weakness, occasional chest pains, trouble sleeping, feeling cold all the time. She was worried, too, about the hepatitis C — another rampant problem among people who inject drugs — she had not been able to treat.
“Nobody will see me because of my drug use history,” Ms. Whitefield said.
Dr. 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,” he said, and added: “I can’t guarantee you won’t need another valve surgery.””
Ms. Whitefield stared at him, stunned.
“Endocarditis causes the most intense inflammation on your body that you can imagine,” Dr. Justice reminded her.
“I just want to live to see my kids grow up,” she choked out.
She would not be denied a second surgery under these circumstances. But she desperately feared the prospect. “Don’t feel like you’re just waiting for the other shoe to drop,” Dr. Justice said, calling her “really pretty miraculous” for not relapsing since the surgery. The praise seemed to sail past her. Still, Dr. Justice had referred her to a gastrointestinal specialist so she could finally see about treating her hepatitis. And with her counselor, she was working on healthy ways of coping with stress, like journaling and hot baths. She had not had a craving for weeks.
“I’m trying to think of ways to get myself more hope here,” she said.