- David Junkin
The University of Vermont Medical Center is grappling with a sharp increase in the number of patients who come to the emergency room with a rare and life-threatening heart infection. Doctors say the opiate crisis is to blame.
In fiscal year 2013, the Burlington hospital treated nine people who contracted endocarditis after abusing drugs. In 2017, that number increased to 59.
"It skyrocketed over the last couple of years," Dr. Stephen Leffler, chief population health and quality officer for the UVM Health Network, said of the endocarditis caseload. "We're concerned about this at every level."
Curing the potentially fatal illness in drug abusers has proven challenging and expensive. Treatment for a single case can cost as much as $600,000.
The illness is an infection of the inner lining of the heart caused by germs — often bacteria such as streptococci and staphylococci— that enter the bloodstream and reach the heart. People with pre-existing heart conditions are susceptible; in rare instances, the infection is contracted during dental procedures when bacteria in the mouth enter the bloodstream.
At especially high risk are injection drug users. Every time they shoot up, bacteria from the skin or syringe, or in the drugs themselves, can get into their veins. Injecting in unsanitary conditions with dirty needles or other unsterile equipment increases the chances of infection.
Historically, the Burlington hospital saw only a handful of endocarditis cases each year. As Vermont's heroin epidemic worsened in 2014, the caseload began to swell. In 2017, endocarditis patients with drug problems have outnumbered clean ones six to one, Leffler estimated.
Other states are reporting similar trends. A Centers for Disease Control and Prevention study found that the number of drug-addicted endocarditis patients in North Carolina rose twelvefold from 2010 to 2015. Hospitalization costs for that population increased from $1.1 million to $22.2 million during the same time period.
Grace Keller has observed the worsening problem firsthand. The program coordinator at the Safe Recovery Support and Education Program, the syringe exchange run by the Howard Center in Burlington, said she's known Vermont drug users who have spent months in the hospital recovering from endocarditis and some who have died.
"It's something that we're talking to our clients about every day," Keller said. Visitors are urged never to share or reuse needles and to always use sterile water when dissolving drugs into injectable form, among other precautions.
Keller said some people don't seek treatment because they fail to recognize that the early warning signs — including fever, sore throat and coughing — could signal a deadly heart infection.
And even when they do recognize the severity of the illness, drug users can be reluctant to seek medical attention because they don't want physicians or family members to find out about their addiction. "As with any other drug-related harm, there's a stigma attached to it," Keller said.
There's also a staggering price tag. According to Leffler, treating one endocarditis sufferer costs between $100,000 and $600,000. Most patients are on government-funded Medicaid; when they're uninsured, the hospital eats the cost.
The most expensive cases are those that require surgery to replace a heart valve. More typically, the infection is eradicated with six weeks of antibiotics delivered intravenously.
Under normal circumstances, a doctor would send the patient home with an IV, but the hospital does not do so for patients struggling with drug abuse. "We're afraid if we let them go home, they'll use their IV access to inject life-threatening drugs," Leffler explained.
Such patients remain in the hospital for the entire six-week treatment — an arrangement far from ideal for everyone involved. Not only does the practice increase costs, it ties up badly needed hospital beds.
Leffler said he's more concerned when patients vacate those beds prematurely, terminating their treatment against their doctor's advice. He said he understands why this happens so frequently. "No one wants to be in the hospital for six weeks," he said. "Some of them get sicker and come back. Some of them don't come back."
Twenty-seven endocarditis patients have made multiple trips to the hospital during the past five years, according to the medical center's data. One person was hospitalized five times during that period.
Five people died from endocarditis in 2015, according to the most recent Vermont Department of Health data. Only two died from the disease during each of the previous two years, although it's not clear how many of the fatal cases involved drugs.
"The way to fix the problem is to have less people using IV drugs," Leffler said. Easier said than done. All endocarditis patients are asked if they want to be referred to an addiction treatment provider, but some are not ready or willing to accept help.
For those who aren't, Safe Recovery's Keller has another idea.
"One of the major ways to combat endocarditis is to expand syringe exchanges," she said. Safe Recovery, the state's largest such exchange, operates on an annual budget of roughly $360,000 — less than the cost of treating a single midrange case of endocarditis.
Syringe exchanges also play a key role in minimizing the spread of other serious diseases linked to injection drug use. In Vermont, new hepatitis C cases have risen from 541 in 2010 to 928 in 2016, according to the Department of Health.
Keller suggested that the state would ultimately save money by investing in centers that provide syringes and guidance about how to safely inject.
Some policy leaders want to take that idea one step further. Chittenden County State's Attorney Sarah George is the latest Vermont official to endorse safe injection sites, which provide a physical location and medical supervision for people to use illicit drugs. Studies have shown that this service can reduce overdose deaths and injection-related infections, a point George has emphasized.
Keller agreed that such sites could further reduce endocarditis infections, though it's unclear whether the Vermont legislature would legalize and fund such a program, especially since the state's top federal prosecutor, U.S. Attorney Christina Nolan, denounced the concept last week.
Leffler isn't convinced safe injection centers would significantly reduce rates of endocarditis. He pointed out that a person could shoot up in a perfectly sterile setting and still get the illness if the drugs themselves contained bacteria.
"It wouldn't serve to fully prevent these infections," conceded Rep. Selene Colburn (P-Burlington), a longtime proponent of safe injection sites. "But it would be a significant tool, potentially, toward reducing them."