When someone suffers a major heart attack, the standard of care is to perform an angioplasty and deploy a stent to open the blocked coronary artery. But this only treats the most immediate problem. In order to prevent future heart attacks (an approach the medical community terms secondary prevention), physicians prescribe medications and provide lifestyle counseling with the goals of improving blood flow as well as decreasing inflammation and cholesterol. The medical profession has been slower to implement a similar approach to treating heart disease associated with injection drug use.
Years ago, I met a patient whom I will call Mr. X, a middle-age man with a longstanding history of intravenous (IV) heroin addiction. His injection drug use (IDU) had precipitated a bloodstream infection that seeded his heart valve with bacterial overgrowth or "vegetation," part of an infectious process known as endocarditis. The incidence of injection drug use-related infective endocarditis (IDU-IE) has soared in the setting of the opioid epidemic, since IDU often starts as problematic use of prescription painkillers. It is estimated that from 2010 to 2015, the proportion of endocarditis cases in the U.S. due to IDU nearly doubled from 15% to 29%. While small uncomplicated vegetations can usually be treated noninvasively with prolonged courses of IV antibiotics, larger vegetations may damage the valve and require open-heart surgery to replace it, which Mr. X initially underwent without complications.
Unfortunately, prosthetic valves are even more prone to endocarditis than native ones, so if patients continue using IV drugs after initial cardiac surgery they frequently succumb to recurrent IDU-IE. This is exactly what happened to Mr. X six months after his surgery. He developed congestive heart failure and suffered several strokes, and his cardiac ultrasound revealed a large vegetation that had destroyed his prosthetic valve. He faced a slim chance of survival without another valve replacement and he was adamant that he did not want to die. But several surgeons declined to operate, citing his prohibitively high risk for yet another endocarditis recurrence from ongoing IV drug use. In case there had been any doubt, a nurse found injection drug paraphernalia in his clothes. Ultimately after the pleading of his family, a senior surgeon took his case and replaced his valve once again.
It is not clear whether efforts were made to arrange substance abuse rehabilitation or whether Mr. X had expressed willingness to participate, but he did not appear to have an addiction treatment plan in place when he was discharged to a physical rehabilitation facility from which he later signed out against medical advice. He was soon readmitted with a third episode of IDU-IE. At this point his disease was so advanced that his family and medical team agreed to focus his treatment on comfort measures only, and he passed away shortly thereafter.
My colleagues and I later discussed this case at length. Some cited the imperative to respect a patient's autonomy or right to self-determination and the duty to replace his valve no matter what. Others invoked the risk-benefit analysis of performing a high-risk and likely futile operation that many would describe as an inappropriate and even unjust allocation of resources when a patient continues to engage in self-destructive behavior.
However, as the medical community has reached an increasingly broad consensus that addiction represents not a moral failing but rather a legitimate medical illness leading to chronic disease with observable changes in brain chemistry that perpetuate these behavioral patterns, this debate may have failed to emphasize the most critical point. American medicine embraces a culture of rescue in which we excel at treating the dramatic manifestations of advanced disease, but the corollary of this culture is an undervaluing of prevention. Routine vaccination to prevent infectious disease may not seem as heroic as powerful antibiotics that pull patients back from the brink of death, but vaccines have saved far more lives than antibiotics ever will. How can we apply this lesson here?
On an institutional level, hospitals need to create protocols that connect patients to addiction specialists who can provide evidence-based treatments such as medications for opioid use disorder while patients remain hospitalized. I am heartened that my institution is piloting a program with a dedicated addiction medicine consult service to ensure adequate addiction treatment after valve replacement surgery to keep our patients from falling through the cracks. On a societal level, we must advocate to destigmatize addiction and adequately fund efforts both to develop and to ensure access to evidence-based means of treating addiction and preventing relapse. This is undoubtedly easier said than done. These labor-intensive resources are costly, these patients often have very limited means, and there is often a lack of political will to make up the difference by allocating adequate taxpayer money.
It is not reasonable to expect patients to recover from opioid use disorder if they are not offered evidence-based treatment. Furthermore, this is a chronic disease and as such patients may experience relapses prior to achieving durable remission and recovery. But regardless of whether patients are able to overcome their addiction, physicians are obligated to treat them to the very best of our ability. Smoking cessation is probably the most important lifestyle modification to reduce the risk of heart attack, but most patients with tobacco use disorder require several attempts before they are successful and many are simply unable to quit.
Still, we would not hesitate to place a stent – or even to perform bypass surgery – for a second or third heart attack for this reason alone. Sometimes we decline to place stents if a patient refuses to take antiplatelet medications to keep them open, as in this case intervention leaves them worse off (not taking these medications with a fresh stent in place can lead to a massive heart attack). Some patients develop advanced coronary artery disease that is simply no longer amenable to intervention. Similarly, there will always be some patients who fail to overcome addiction despite everyone's best efforts to help them, and at a certain point, we need to be able to say enough is enough when we truly believe further surgical intervention would be futile and potentially do more harm than good.
But categorical refusal to intervene because of "bad behavior" -- regardless of whether that behavior is due to what we perceive as a moral failing or what the medical community has demonstrated to be a legitimate disease with organic underpinnings -- violates our obligations as physicians. Some may argue that this is not a valid comparison because smoking is not illegal. But as physicians it is not our duty to enforce the law; it is our duty to provide the best evidence-based care to patients.
To that end, it is essential to note that truly providing the best care will require not only concerted efforts to promote secondary prevention, but also more focus on primary prevention – that is to say, preventing opioid abuse and addiction in the first place. We need to hold pharmaceutical companies and distributors accountable for deceptive marketing practices and inadequate oversight. Physicians need to commit to better opioid stewardship to decrease unnecessary and unsafe exposure to addictive medications, from more comprehensive education initiatives in medical school to more judicious prescribing practices. Of course, inadequate treatment of pain is also a serious problem in medicine, and we indeed have a duty to alleviate suffering. Some patients may truly require high doses of opioid analgesics to maintain a reasonable quality of life. However, we should allocate more funding toward developing alternative pharmacologic and nonpharmacologic methods of pain control for those who do not.
We have an extremely robust toolkit of both medical and lifestyle interventions that we know to be effective in both primary and secondary prevention when it comes to managing coronary artery disease and many other medical conditions. We can and must do better in the prevention and mitigation of opioid addiction and its devastating complications.
Sarah C. Hull, MD, MBE, is an assistant professor of clinical medicine (cardiology) at Yale School of Medicine in New Haven, Connecticut.