Program for Biomedical Ethics Program Ethical Considerations in the Management of Injection Drug Use Related Infective Endocarditis

January 30, 2024

January 17, 2024

Program for Biomedical Ethics Program

Ethical Considerations in the Management of Injection Drug Use Related Infective Endocarditis

Melissa B. Weimer, DO, MCR, DFASAMAssociate Professor of Medicine & Public Health, Yale School of Medicine & Public Health

Medical Director, Yale Addiction Medicine Consult Service, Yale New Haven Hospital

Associate Program Director, Yale Addiction Medicine Fellowship Program, Yale Program in Addiction Medicine

Sarah C. Hull, MD, MBE

Assistant Professor of Medicine (Cardiology)

Associate Director, Program for Biomedical Ethics, Yale School of Medicine

Information

ID: 11237
To Cite: DCA Citation Guide

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00:00All right. Good evening and welcome.
00:05Are we good? All right.
00:07Thank you so much. And welcome to
00:09the Program for Biomedical Ethics,
00:11our first evening ethics seminar for 2024.
00:14I'm, I'm delighted that you're here tonight.
00:17I'm the folks who are here and are
00:19we broadcasting now? I'm here.
00:20Is this, is this happening?
00:21Outstanding? All right.
00:22And so until I know how many
00:24friends are coming from outside,
00:25including my friend Catherine from
00:27Columbia and so many others who were,
00:29we're phoning in. So we appreciate that.
00:32Tonight's conversation is the
00:35brainchild of Sarah Hall,
00:37our associate director and she's
00:38also one of our speakers for tonight.
00:40It's a fascinating subject.
00:41We're going to talk about ethical issues
00:43that arise with four drug abuse and
00:46endocarditis in the treatment of such.
00:48And Sarah knew exactly who we wanted
00:49to invite for this conversation.
00:51So I'll introduce them both to you.
00:52Now the the the first speaker I
00:54think is going to be Melissa.
00:56Yes.
00:57So Doctor Melissa Weimer is a nationally
01:00recognized Educated rank clinician
01:01who's board certified at Internal
01:03Medicine and Addiction Medicine.
01:04She's an associate professor of
01:06medicine and public health at the
01:07Yale School of Medicine and the
01:09Yale School of Public Health.
01:10She's also the medical director of
01:12the Yale Addictive Medicine Counsel
01:14Service at Yale New Haven Hospital.
01:17She's the Associate program director
01:19for the Addiction Medicine Medicine
01:21Fellowship Program here as well.
01:23Doctor Wamer has clinical and
01:25research focus on expanding access
01:27to treatment for individuals with
01:29substance use disorders,
01:30particularly in the hospital setting.
01:32Doctor Weimer has ABA from the
01:34University of Virginia,
01:35ADO from Virginia College of
01:38Osteopathic Medicine.
01:39She trained in medical residency
01:41and fellowship as well as a Master's
01:43in clinical research from Oregon
01:45Health Sciences University.
01:47That is our first speaker for tonight,
01:49Melissa Weimer, Dr. Weimer.
01:50So I think I'll wait and I'll
01:52introduce our second speaker after
01:53Doctor Weimer has a chance.
01:54But just to let you guys know how this works,
01:57many of you do, some of you may not.
01:59So we'll hear from the each speaker
02:01for about 15 or 20 minutes.
02:02Please hold your rousing questions
02:04until afterwards and then we'll
02:06have a question and answer session.
02:08And the folks who are on Zoom,
02:09you could send in your questions
02:11via the Q&amp;A function on the Zoom
02:13call and we will have a hard stop at
02:156:30 and everybody in the room has a
02:18atomic clock in their pocket, I know.
02:20So we all know when 630 happens.
02:22So I apologize in advance if you had
02:23something you really wanted to ask.
02:25And at 6:29 because I am going
02:26to end us on time,
02:27in case you're wondering because I
02:29know you guys want to go out and
02:30enjoy the enjoy the outdoors tonight.
02:32So we'll get to that.
02:33So let's start,
02:34please with with doctor Weimer.
02:36Please join me in welcoming
02:38Doctor Melissa Weimer.
02:43Thank you. Pathetic. Here. If you push
02:47forward beautiful things should happen.
02:50Curry. There you go.
02:52All right. Thank you so
02:54much for the invitation.
02:56It's wonderful to be here tonight.
03:00All right. I think I can see everything.
03:01I can sort of see you all.
03:03So hopefully you can see me.
03:05So tonight, I'm honored to be talking
03:08to you about ethical considerations
03:09in the management of injection drug
03:12use related infective endocarditis.
03:14And I appreciate the introduction.
03:20I don't have any disclosures.
03:23So I know we have a broad audience.
03:25So I just want to start with
03:27some very simple grounding of
03:28what is infective endocarditis.
03:30Because you know,
03:31when I talk to my family about what I do,
03:33they're very confused and they're like I
03:35have no idea what you're talking about.
03:37So I know we have a various audience.
03:39So infective endocarditis is a very
03:43serious life threatening infection
03:45that's generally caused by bacteria
03:48or fungi and generally caused by
03:51those bacteria or fungi being in
03:54the bloodstream and they can cause
03:56growth on the various heart valves.
03:58You have heart 4 heart valves in
04:01your heart and you can get these
04:04vegetations that occur from bacteria
04:06or fungi on the heart valve and
04:10this can be very life threatening,
04:12very serious,
04:12lead to serious infections that
04:14are very hard to treat.
04:19So before moving on,
04:21I want to also give a bit of a
04:23historical perspective to show how
04:25our understanding of endocarditis and
04:28its treatment has evolved over time.
04:30So infective entocarditis was
04:32first described by Revere in 1646.
04:35So nearly 400 years ago,
04:38Osler and Libman and actually many,
04:40many other people had recognized and
04:44described infective entocarditis.
04:46But Osler and Libman are really recognized
04:49for determining this relationship between
04:52infection and endocarditis in the 1800s.
04:55And then famously,
04:56Gustav Mahler was,
04:58who's a famous composer,
05:00was a famous composer.
05:01He developed infective endocarditis
05:03related to rheumatic fever he had as a child,
05:07and that ultimately led to his death.
05:09And Littman actually was a microbiologist
05:12who he had consulted with at the time,
05:16about six months before his death
05:18to kind of describe what was going
05:20on and and why it was happening.
05:25So let's go forward nearly 350 years to 1967.
05:31And this was when infective
05:33endocarditis was first recognized
05:35to be a medical complication of,
05:37quote, heroin addiction,
05:38which I'm going to refer to as opioid
05:42use disorder throughout my talk,
05:44or just plainly addiction.
05:47This occurred in 1967 before we
05:50really had broad use of medications
05:52that are highly effective,
05:54such as methadone or buprenorphine
05:57that we know are highly effective
05:59to treat opioid use disorder.
06:01In this manuscript from 1967,
06:04the authors described how individuals
06:07who use injection drugs go on to
06:10develop infective endocarditis.
06:12And so they described The heroin is
06:15then injected intravenously without
06:17any attempt at skin cleansing.
06:19The user commonly injects the heroin in
06:21the presence of one or more fellow users,
06:24the group often sharing the needle
06:27without any attempt at sterilization
06:29between intravenous inoculations.
06:31It is a Small wonder that self
06:34administration of opiates in this fashion
06:37produces severe medical complications.
06:39So this is when we really
06:41determined that there was this
06:42relationship between injection drug
06:44use and effective intercarditis.
06:46And I'll refer to this throughout the
06:48talk as injection drug use related
06:51infective intercarditis or IDU i.e.,
06:53because it's quite a mouthful to
06:56say all of those words at once.
07:00So let's go forward another 50 years to 2010.
07:07So in 2010 we see that, you know,
07:10medical treatments have
07:11really become more advanced.
07:13But yet our medical community is
07:16still struggling with how do we best
07:19treat individuals who have IDU i.e.
07:21And there's this AMA Journal
07:23of Ethics Case and commentary.
07:25And the author describes questions
07:28that this physician named Doctor
07:31Collins asked of his patient Mr.
07:33Addison, who has developed infective
07:36endocarditis that appears to be
07:38prosthetic valve endocarditis,
07:40The author writes.
07:41The typical clinical management approach
07:43would be to examine the patient and
07:46recommend that a surgeon be consulted
07:48to discuss emergency valve replacement.
07:50But Doctor Collins paused.
07:53Mr.
07:53Addison's relapse was almost certainly
07:57a direct result of his renewed drug use.
08:00Doctor Collins could just turf the
08:02case to a cardiac surgeon and leave
08:04the decision up to him or her.
08:06But he wondered whether he had
08:09some responsibility to intervene
08:10at this point and ask them serious
08:13questions about the use of medical
08:15resources and money to keep patching
08:17up people who abuse their bodies
08:20in this instance unlawfully.
08:23And as I read that and I talk
08:24to you about it,
08:25it's hard for me to actually
08:27understand that that was 2010.
08:29This wasn't even that long ago that you
08:33hear someone describing an individual
08:35who has this condition in this way.
08:42So also in 2010, I had my own
08:45career changing experience treating
08:47an individual with injection drug
08:50use related infected endocarditis.
08:52I took care of a patient named Samantha
08:55and she showed me how incredibly
08:57flawed our care for patients with
09:00substance use disorder or addiction
09:03and affective endocarditis is.
09:05At the time, I was working as a general
09:08internist in an academic primary care clinic.
09:10I just finished residency in Portland,
09:12OR and I also had a weekly addiction
09:15care clinic that was embedded
09:18in the primary care clinic.
09:20I received an urgent call from a
09:22colleague who'd asked me to come see
09:24this woman in the hospital named
09:26Samantha who was on the medical
09:28wards because she had infected
09:30endocarditis and my colleague had
09:32called me because Samantha was having
09:35severe post operative pain from an
09:37open the open heart surgery that
09:40she just underwent 2 days earlier.
09:42At this time in my career I really
09:44did only outpatient medicine.
09:46I would sometimes see patients
09:48on the wards as a hospitalist or
09:50an academic hospitalist.
09:51But you know,
09:53this was an urgent situation and
09:55a colleague was calling me for
09:57for my expertise.
09:58So I made an exception to go see Samantha and
10:02we were able to get her pain under control.
10:07Over the time that I started
10:09to care for Samantha.
10:10Because I continue to care for her.
10:12During the hospitalization,
10:13I got to know her a bit more,
10:17became clear that she had a very,
10:19very hard childhood.
10:21She left, she left home.
10:24She ran away from home at the age of 16.
10:26She'd been living in a van by herself
10:29on the outskirts of Portland,
10:31and her most trusted allies
10:33in life were her two dogs.
10:35This is not a picture of her,
10:37but similar.
10:37You can sort of think of a similar
10:40picture of of what she might have
10:43looked like being unhoused or UN
10:45unstably housed on the streets.
10:49She developed infective endocarditis
10:51from injecting opioids and cocaine,
10:53which she had been doing over
10:54the last five years,
10:56and she'd never really been able
10:59to get any formal treatment for it.
11:02She was most worried about her
11:05dogs during the hospitalization,
11:07and that was sort of her primary concern.
11:09She understood she had a serious infection,
11:11but from her perspective,
11:12you know, she'd had surgery,
11:14she's getting antibiotics, things were fine.
11:16She really wanted us to be able to
11:19accommodate her dogs in the hospital.
11:21And though Portland OR
11:22is a very liberal city,
11:24we were not able to accommodate
11:26her two dogs coming to visit her,
11:28even though I did try.
11:30And those who know me know
11:32that I absolutely did try.
11:37So anyway, we weren't able to accommodate
11:39that and she unfortunately made the decision
11:42to prematurely leave the hospital quickly.
11:45Things were put together as are done for
11:47someone who's prematurely leaving the
11:50hospital and kind of unbeknownst to me,
11:52she she left the hospital with a prescription
11:55for 200 tablets of hydromorphone,
11:57which was for her post operative pain.
12:00She did agree to see me a
12:02couple days later in my clinic,
12:04which was amazing, and I saw her.
12:07She looked terrible.
12:09I talked to her about the
12:11need to consider treatment,
12:13consider going back to the hospital,
12:15but she didn't feel that she could do
12:18either of those things at the time.
12:21Unfortunately,
12:22she was hospitalized 5 days later.
12:25She came back in with severe septic
12:28shock and died within 24 hours.
12:33Samantha changed my career.
12:36She also changed the health system
12:38I was working in because colleagues
12:39and I decided that we had to do
12:42better for her and all the other
12:44patients who deserved better care.
12:46So colleagues and I came together at
12:49this time and we developed a hospital
12:52based addiction medicine consult
12:54service to help patients like her.
13:01So what I recognized at the time
13:02that I was caring for her was
13:04that we have all these amazing,
13:06complex, you know, medical and
13:08surgical care that we can provide.
13:10We can spend millions of dollars to
13:13to patch people up to, you know,
13:15take out their valves to get them better,
13:18to, you know, intubate them, put them
13:20on pumps and ECMO and all this stuff.
13:22But we don't seem to be able to address
13:26their addiction for some reason.
13:28And so colleagues and I wrote about this
13:32as in this article stating that, you know,
13:34we're treating the symptoms of the illness,
13:37but we're not treating the underlying disease
13:39of addiction in infected endocarditis.
13:42So why can we give six weeks of IV,
13:45you know, powerful IV antibiotics
13:47and these complex surgeries,
13:48but we can't talk to our patients
13:50about what's really going on,
13:52what's really leading to their
13:54hospitalization so that they can
13:56truly get better and recover and
13:58stay well and prevent future harms.
14:05So not addressing addiction during
14:07hospitalization for IDU i.e.
14:09was also placing our surgical
14:11colleagues in a terrible position.
14:13This was written about in the New
14:16York Times in 2018 that highlighted
14:18A cardiac surgeon from Knoxville,
14:21TN who is describing his experience
14:24caring for individuals with IDU i.e.
14:27He stated certain cases haunt him.
14:31A little over a year ago he
14:33replaced a heart valve in a 25 year
14:35old man who had injected drugs,
14:37only to see him return a few months later.
14:39Now two valves, including the new one,
14:42were badly infected and his urine
14:44tested positive for illicit drugs.
14:46Doctor Pollard,
14:47the surgeon he declined to
14:49operate a second time,
14:50and the patient died at a Hospice.
14:53It was one of the hardest things
14:54I've ever had to do, he said.
14:57Doctor Pollard worked with his health system
15:00to start providing addiction treatment.
15:02This is a cardiac surgeon who
15:04worked with his health system to
15:06start providing addiction treatment
15:07to individuals with IDU i.e.
15:09Because he also recognized without
15:12addressing the underlying disease,
15:14his patients couldn't actually get better.
15:20So over the last 20 years,
15:23as we've seen the opioid overdose epidemic
15:26increasing and our drug supply becoming
15:29incredibly lethal with the introduction
15:32of synthetic opioids like fentanyl,
15:34unfortunately the incidence of IDU i.e.
15:38Has increased in parallel despite rates
15:40of infected entocarditis not related to
15:43injection drug use really staying flat
15:45as you can see in the green line here.
15:48So the incidence rates of entocarditis
15:50among patients with opioid use
15:53disorder or those who inject opioids,
15:55for instance, increased from 3.7
15:58in 2011 to 30.1 in 20/20/22 and
16:03accelerated during the COVID pandemic,
16:05which something could be
16:07actually related to the virus,
16:08potentially accelerating risk of infection.
16:12The incidence rate is 3 to 8 times that
16:15of individuals who don't inject drugs,
16:18who go on to develop infective intercarditis.
16:23As you can imagine, hospital costs
16:25have similarly increased over time.
16:27And this is old data at this point.
16:29But really the best data that I could
16:31find or the most up to date data that
16:33I could find showing that you know
16:35the great increase in hospital costs
16:37which have in this study increased
16:41818 times or 18 fold up until
16:452015 and I imagine have increased
16:48even more over the last 10 years.
16:56So recognizing we have an opportunity
16:58and responsibility to improve the
17:01care of individuals, with IDU i.e.,
17:03the American Heart Association wrote a
17:06scientific statement in 2022 to provide
17:09guidance for the management of infective
17:12intercarditis in people who inject drugs.
17:15And I was, you know, happily agreed to
17:18be part of this distinguished group.
17:21What was interesting when I was part of
17:23this group was that everyone was kind of
17:26looking to me to tell them what do we do?
17:30And I was like, guys, I don't,
17:32I don't treat this alone.
17:34I mean, yes, we need to treat addiction,
17:36but they're like, but we can't do any
17:38of our things that we do without you.
17:41So it was kind of this amazing moment
17:42in my career where I was like,
17:44yes, absolutely.
17:45You know,
17:46I was so excited to have this this
17:50interest and so happy to see headlines
17:52like this coming out and people
17:55starting to understand that addiction
17:57management is the key to treating heart
18:00infection in people who use drugs.
18:03So thankfully there has been this shift.
18:05It took us many hundreds of years but that's
18:09addiction treatment is slow and steady.
18:13We just keep going.
18:14So thankfully it's now
18:16understood that we have to have
18:18addiction medicine at the table,
18:20particularly for people who have injection
18:23drug use related infective endocarditis.
18:28So let's talk a little bit about addiction,
18:30one of my favorite topics and
18:32how we can best safely, safely,
18:36and effectively treated.
18:37So the American Society of Addiction
18:40Medicine defines addiction this way,
18:43and the emphasis here and the is mine.
18:46So addiction is a treatable,
18:50chronic medical disease involving complex
18:53interactions among brain circuits,
18:56genetics, the environment,
18:58and an individual's life experiences.
19:01People with addiction use substances
19:03are engaged in behaviors that combine,
19:05that become compulsive and often
19:08continue despite harmful consequences.
19:11Prevention efforts and treatment approaches
19:13for addiction are generally as successful
19:17as those for other chronic diseases.
19:21So I love this definition because there's
19:23a lot of hope in this definition.
19:26I think a lot of people,
19:27when they think about addiction,
19:28they don't think about hope.
19:31They don't think that this is a treatable
19:35condition because maybe there's just
19:37not enough understanding that there are very,
19:39very safe and effective treatments.
19:41So I think understanding that it's treatable,
19:44understanding it's a
19:45medical disease is really,
19:47really important when we're having
19:49any sort of conversation about
19:52how we best integrate the care
19:54into into our hospital systems,
19:56into our outpatient clinics,
19:58all of that.
20:01So for the purposes of this talk,
20:03I'm going to focus on opioid use disorder.
20:06So addiction is the disease.
20:08Opioid use disorder is how we define,
20:11define or treat the diagnostic
20:14classification of how we define
20:17the disorder which is addiction.
20:19So I'm going to focus on medications
20:22for opioid use disorder though
20:25recognize that other injection drugs
20:28such as cocaine or methamphetamine
20:30that can also cause injection drug
20:33use related infective entaccarditis,
20:34but primarily in our region where we don't
20:38have as much injection of those substances.
20:41Most of the injection drug use related
20:44infective entaccarditis is from opioids.
20:47So the three effective medications for
20:48the treatment of opioid use disorder
20:50are buprenorphine, extended release,
20:52naltrexone and methadone.
20:53Those are in no specific order
20:56other than alphabetical order.
20:57They have multiple benefits to patients.
21:00So I've listed some of those here.
21:02We talked about addiction being a brain,
21:06a disease of the brain,
21:07medical disease.
21:08And So what these medications do are restore
21:12brain networks which support recovery.
21:15They reduce compulsive drug use and craving.
21:18They promote retention and treatment
21:19which we we know is sort of foundational.
21:22For people to get better,
21:24they need to stay in treatment.
21:27But importantly,
21:28particularly when someone has a an
21:31illness such as infective inner carditis,
21:33it also helps them complete
21:35those medical treatments,
21:36stay in the hospital for needed care,
21:39continue care in a, you know,
21:41nursing facility or outpatient
21:43wherever they are.
21:44It improves psychosocial functioning,
21:47reduces all 'cause mortality as much as 60%.
21:51We actually don't have many therapies
21:54or medications in medicine that
21:57improve all 'cause mortality,
21:59mortality from anything as
22:02much as these medications
22:04do for opiate use disorder,
22:06reduced risk of opioid overdose,
22:08reduced risk of HIV,
22:10hepatitis C and reduced healthcare costs.
22:12One important thing to recognize
22:14though is that it's not enough
22:16to just offer these medications
22:19or initiate these medications.
22:21We need to help patients stay on these
22:24medications because actually when we
22:26have detox only protocols or we only
22:28provide withdrawal management for instance,
22:31we actually could be placing our
22:33patients at a higher risk of death.
22:35And in fact, we've shown that when
22:38these medications are stopped and
22:40people have recurrence of opioid use,
22:42their risk of death precipitously goes up.
22:46So it's really important that
22:47we not only initiate,
22:49but we help patients stay
22:51on these treatments.
22:55So a lot of times, you know,
22:57when I'm treating patients in the hospital,
23:00they'll say to me,
23:01they'll say all kinds of things to me.
23:02I've heard it all really.
23:04I'm sure I haven't heard it all,
23:05but sometimes I feel like I've heard it all.
23:08And one of the most common
23:09things they'll say is,
23:10you know, I don't want to,
23:11I don't want to trade one addiction
23:13for another or this is just, you know,
23:16this is, this is not going to help me.
23:18I don't need this medication.
23:20So this might be a slide or a
23:22graphic that I'll show them,
23:24which shows that like, this is what
23:26happens when you start using substances.
23:28You usually start using a substance because
23:30you you want some sort of positive benefit.
23:33And initially people do generally
23:35have a positive benefit.
23:37Maybe they're trying to escape
23:39trauma or anxiety or who knows,
23:42they they start using for some reason and
23:44in the acute period they might feel OK,
23:47they might feel pretty good and they might,
23:50you know,
23:50really have some of that positive benefit.
23:53Unfortunately,
23:54over time and particularly with opioids,
23:56what happens is you quickly
23:58develop tolerance to this,
23:59to the opioid and you also quickly
24:02develop physical dependence.
24:04So the medicine or sorry the the opioid
24:06actually no longer is providing a lot
24:09of the benefit that you're seeking.
24:12And people,
24:12most of the people that we're seeing
24:14in the hospital setting who are
24:16coming in with opioid withdrawal,
24:18these are individuals who are using
24:20multiple times a day to really
24:22just feel at all kind of balanced,
24:25right.
24:25They're spending a lot of time
24:27in that withdrawal period that
24:29they're trying to escape.
24:30So the reason it's not treating one
24:33addiction for another is this because
24:36methadone and buprenorphine don't
24:37keep people in that period where
24:40they're having those highs and lows.
24:42It really you know keeps people
24:45in this equilibrium point and so
24:48there's a lot of education we need
24:50to do to help people understand,
24:52understand that.
24:55So you might say is there any data
24:57to suggest that these medications
24:59work and help people who have
25:01specifically have injection drug
25:03use related infective endocritis.
25:05And in fact, there was a great
25:07study out of Boston, Simeon,
25:09Kimmel and others from 2020 that showed
25:13that with the use of medication,
25:16specifically medications to
25:18treat opioid use disorder,
25:20we see a decreased all 'cause mortality.
25:24We see that when the medications
25:27are given and continued.
25:28So importantly,
25:30that benefit goes away if the person
25:33doesn't stay on the medication.
25:36So This is why when we're seeing
25:38patients in the hospital,
25:39it's important that we're not just
25:41again starting the medication,
25:42but really talking to patients about
25:45the need to stay on the medication
25:48to promote their ongoing recovery
25:50and hopefully get them to a period of
25:54remission from opiate use disorder.
25:58So despite knowing all of this, the things,
26:00the wonderful things I just said,
26:02medications for opiate use
26:04disorder are hugely underutilized.
26:06In 2020,
26:07which was the year that we had
26:09100,000 people die of an opioid
26:11overdose and 2.5 million people who
26:14who answered survey results saying
26:16that they had an opioid use disorder,
26:19only about 11% of them received
26:21safe and effective treatment for
26:23their opioid use disorder.
26:25So that left 89% of the population
26:28of people with opioid use disorder
26:31without treatment.
26:35So to lead quality care and to provide
26:39patients treatment at the bedside,
26:41I am proud to lead this team in the
26:44hospital at Saint Raphael's campus
26:46in York Street campus that provides
26:49medication treatment to patients
26:51who have substance use disorder.
26:53So we see patients who are in the hospital
26:55with endocarditis or alcohol withdrawal
26:57or whatever they might have related
26:59to their substance use and we provide
27:02treatment to them while they're there.
27:06Our treatment model is to see these patients,
27:09evaluate them, provide a diagnosis,
27:11talk to them about their treatment
27:13options and initiate medication
27:14treatment in the hospital.
27:16We don't want patients to wait till
27:18after the hospitalization because
27:20sometimes that can be too late.
27:22And then we want to talk to them
27:23and help educate them about the
27:25need for ongoing treatment,
27:27continuation of medication,
27:2830 day follow up.
27:30And this is all built on this framework
27:32of motivational interviewing,
27:34brief treatment and importantly harm
27:36reduction because we know that not all
27:38of our patients are going to want to
27:40potentially start these medications
27:42or stay on these medications.
27:44So we also need to talk to them
27:45about how to prevent future harms.
27:50Something else we've done as a
27:52part of our work is the wonderful
27:55volunteer multidisciplinary
27:56endocarditis evaluation team which
27:58myself and Doctor Hall are a part of.
28:01Had a meeting this morning talked
28:03about a patient who has injection drug
28:06use related infected endocarditis.
28:08And this is a multidisciplinary
28:10group of cardiac surgeons,
28:12cardiologists, ethicists,
28:14care managers, addiction medicine ID.
28:19Who am I forgetting?
28:22Lots of people who meet and we talk
28:25about the care for individuals who
28:28might need surgical intervention
28:30for their endocarditis,
28:31kind of similar to like a
28:33tumor board that might meet.
28:35And our aim is really to initiate
28:37multidisciplinary care and ensure
28:39their patients are getting appropriate
28:41assessment and treatment and optimize
28:43the treatment that they're receiving,
28:45facilitate resources and promote
28:47communication about challenging situations.
28:50There are times where,
28:51you know,
28:52I may really think that a patient
28:54absolutely needs surgery and the
28:56surgeon may say I don't agree with you.
28:58So we need a time where we can
29:01talk about that and recognize that
29:03it's important that we're having
29:06those tough conversations together.
29:11We also need to recognize that, as I said,
29:14not all of our patients are going to
29:16be ready or willing to stop using.
29:18We also need to recognize that as we said,
29:21addiction is a medical disease.
29:23It means like other chronic medical diseases,
29:26it can happen or recur.
29:29So we know that relapse can be
29:31a part of the disease pattern.
29:34And so we need to talk to our patients
29:37through all the stages of change,
29:38which are illustrated here,
29:40recognizing that you know at many
29:42of those stages they might still
29:44have ongoing use of substances.
29:47Most of the time in the hospital
29:48we're able to avoid ongoing use.
29:50So it's a great reachable moment
29:53for us to be able to talk to them,
29:54create action plans and hopefully
29:57get them to that maintenance part of
30:00treatment where we can really you know
30:03sustain change which we know takes time.
30:06But when relapse happens or
30:08recurrence of drug use happens,
30:09we also need to remain hopeful and
30:12recognize that it's an upward spiral
30:14that we can learn from each of those
30:16times and we can help our patients
30:18as long as we keep an open door and
30:21optimism that they can get better.
30:27Talking a lot about harm reduction,
30:29we know that a lot of our
30:31patients aren't ready to change.
30:33They they might have a lot of questions
30:36about how they can can stay healthy,
30:39but maybe they're not ready to commit
30:41to buprenorphine or methadone or or
30:43whatever medication we talk about.
30:45So we've also developed a website
30:47which is freely available.
30:49Any of you could access
30:51it safer substanceuse.org.
30:53This was funded by the Yale New
30:58Haven Hospital Medical Staff Fund.
31:00So with that fund,
31:02we built this website which talks
31:04through ways that that people Canmore
31:06safely inject alternatives to injection
31:08and also helps clinicians be able to
31:11talk through this with their patients.
31:14If they're not sure how do you talk
31:16to somebody about injection drug
31:17use because you probably didn't
31:19learn about that in medical school.
31:21So this is a great, great resource as well.
31:26So my goal is that all patients who
31:30might have injection drug use related
31:32infective intercarditis in all health
31:34systems around the country which we
31:37know that you know console services are
31:39not available in many of these places.
31:41But I hope that at least life saving
31:44medications such as, you know,
31:46medications for opioid use disorder are
31:49provided to patients in these settings,
31:51particularly if they have
31:53infective intercarditis.
31:54And hopefully by doing so,
31:55we can change the story Samantha's story.
31:59And so maybe it'll be a comeback
32:01story instead of a sad story.
32:03Yale New Haven Hospital likes
32:05their comeback stories.
32:05So a dream of mine is, you know,
32:08I'm driving down 95 and I'm going to
32:10see this comeback story and it's going
32:12to say after treating her opioid use
32:14disorder and infected intercratitis,
32:15Samantha came back faster.
32:17So thank you.
32:28Thank you very much, Doctor Weimer,
32:33Karen had posted briefly.
32:34We saw it up there real small.
32:36I saw it in front. The CME code.
32:38For those of you in the room,
32:40the folks on Zoom probably got it,
32:41but could you say again out loud
32:42what that CME code is in case
32:44anyone in the room is trying to use
32:48it? 40970 All right.
32:51I'm gonna try it. Sounds good.
32:57Thank you, Karen.
32:59Our second speaker tonight is the
33:02associate director, of course,
33:03of the Program for Biomedical
33:04Ethics here at Yale. Dr.
33:06Sarah Hall completed her undergraduate
33:08education at Harvard University,
33:10where she got an AB in biochemical sciences.
33:13She earned a master's of bioethics
33:15along with her medical degree
33:17at Penn where she remained for
33:19her internal medicine residency.
33:20Then she course she came here to Yale
33:22for a cardiology fellowship and after
33:24completing her training in 2014,
33:26she joined the faculty. Dr.
33:28Hull is a board certified
33:30cardiologist and echocardiographer
33:31whose clinical practices focused on
33:34echocardiography and cardio oncology,
33:36which is to say the cardiac
33:38care of cancer patients.
33:39She is the cardiology course director
33:40here at Yale School of Medicine.
33:42So I assume you guys either know her or
33:44you're going to know her pretty soon.
33:45So don't say anything to
33:46**** her off tonight.
33:50And of course she's the associate
33:52director of our program.
33:53Sarah's is is highly
33:55accomplished in cardiology,
33:56certainly in cardiac oncology,
33:57but also in particular in the
33:59field of biomedical ethics.
34:01So bringing her interests
34:03together is perfect.
34:04This is the perfect setting for that.
34:06We're delighted to have a few minutes
34:07to listen to Doctor Sarah Ho.
34:08Thanks.
34:16Can everyone hear me? OK, great.
34:19Thank you for that very kind introduction
34:22and thanks again to my colleague Dr.
34:24Weimer for that incredible talk.
34:25I I have to say that is it's
34:27going to be a tough act to follow.
34:29But I I'm going to try to piggyback on
34:32a lot of the the points that she raised
34:35you know with with some ethical analysis
34:38to think about and challenge some of
34:41the the more historical assumptions
34:43about the treatment of this disease.
34:45And what might be a a more ethical
34:48and and also more medically accurate
34:50way to to approach the treatment of
34:52injection drug use related infective
34:54endocarditis or as I will also say IDU i.e.
34:57because that is quite a mouthful.
35:00So I do not hey,
35:03one second let me this will be better.
35:07I have no
35:07conflicts of interest to disclose,
35:10but I will disclose that Doctor Wyman
35:13and I in addition to some other members
35:16of the meet that that she mentioned last
35:20year published this piece reviewing a lot
35:23of what I'm going to talk about today.
35:25So you can see that for for further details.
35:27So most of this is pulled from there.
35:29So just very briefly going through
35:33just some introductory points that I'm
35:35not going to belabor because Doctor
35:37Weimer covered them so beautifully.
35:38Ongoing opiate, the ongoing opioid
35:40epidemic has precipitated a a really
35:42strikingly increasing burden of
35:44injection drug use related infected
35:46endocarditis and which actually now
35:48accounts for a third of all valve
35:50surgeries performed for endocarditis in
35:53the US which is just staggeringly huge.
35:56Like with many chronic diseases there
35:59that are relapsing remitting in nature,
36:01there is a high risk of recurrence
36:03in these patients that often can
36:05require repeat valve replacement.
36:07And at least historically we've often
36:09heard of of reoperation being denied
36:12on the basis of purported futility,
36:14which we're going to touch upon a
36:16little bit later given the increased
36:18risk of recurrent injection drug use.
36:20All
36:23right. So let's talk again a little
36:25bit about the nature of addiction.
36:27I won't belabor this because Doctor
36:29Weimer covered it so nicely.
36:30But again, focusing on the definition
36:31of addiction as a treatable and chronic
36:34medical disease that involves complex
36:36interactions among brain circuits,
36:37genetics, the environment and
36:39individual life experiences.
36:40So addiction's a medical disease
36:45too often, I I think.
36:46And and this is slowly changing,
36:50but I think it's too often treated implicitly
36:52if not explicitly as as a moral failing.
36:54I I think we've gotten to a point where
36:56it's not often explicitly cast in that way.
36:58But I I think there's still a lot
37:00of implicit bias in the way that we
37:02speak about about these patients.
37:04And you know I've learned so much
37:07from Doctor Weimer and and I'm sure
37:09I was guilty of this at at at times
37:11as well because it's so the the the
37:13what makes implicit bias so pernicious
37:15is that of course you're not you're
37:17not aware of it because it's so baked
37:19into the the systemic limitations
37:22and discrimination that exist.
37:25And you know I I also think that
37:27that part of the reason that that
37:29the stigma has been so persistent is
37:32because the the nature of addiction
37:35is so it's it can be so devastating
37:38that that we often have.
37:40This has been well described in in
37:42in psychology that you know that we
37:44have a cognitive bias to think that
37:46when really terrible things happen
37:49they we want to think that they
37:51don't happen to quote good people.
37:52Because the idea that this kind
37:54of thing could happen to me,
37:56that's so terrifying that we don't
37:58want to think about that, that that's,
37:59you know, that's why, for example,
38:01there's a lot of stigma against poverty.
38:03This idea that, well, you know,
38:05these people are in poverty because
38:06they made bad choices,
38:07not because they were constrained
38:10by different life circumstances,
38:11because it's it's very, it's it,
38:14there's a lot of cognitive distance
38:16that comes from and a lot of fear,
38:17frankly, that comes from the idea that,
38:19you know, if if I,
38:20if it were not for these accidents
38:23of fortune,
38:23maybe I would have ended up like this.
38:26For a lot of people,
38:26that's that's just too harrowing
38:28to contemplate.
38:28And it's easier to think, well,
38:30I would never be like this.
38:33And so I think we,
38:33we really need to interrogate
38:35that within ourselves the,
38:36the discomfort that that we feel
38:39realizing that, you know, no,
38:40no one chooses to have an addiction, right.
38:42That's not some.
38:43That's not a goal that people have.
38:44They they fall into that.
38:47Now you can say, well, you know,
38:50addiction is, you know,
38:51it at least begins as the result
38:53of of unwise choices.
38:54Even if once you are struggling
38:56with addiction,
38:57you know,
38:57it's no longer really a choice to use.
38:59And OK that's that's fair to an extent.
39:03But I think that number one again
39:06we have to recognize that that
39:08while free will is important to the
39:10degree of free will that you have
39:12is typically constrained by the
39:13systemic limitations in which you
39:15live in which you've been raised
39:17in which you continue to operate.
39:19And realizing that that often
39:22people's it's really hard to
39:24understand why people make the
39:25choices they do not understanding
39:26the circumstances that they're in.
39:29And I and I think equally importantly
39:32the the same can be said
39:33of many chronic diseases.
39:34You know certainly in the United
39:36States and in the developed world
39:37most of the diseases that we
39:39treat are diseases of lifestyle.
39:41The the number one cause of of
39:44mortality in the US and worldwide
39:46is cardiovascular disease And of
39:47course I'm a cardiologist you know
39:50a lot of cardiovascular disease
39:52is the result of an unhealthy
39:55lifestyle and and I often we we,
39:58we sort of use that term interchangeably
40:00with unhealthy lifestyle choices.
40:02But I want to be careful about even
40:04using that term because we also again
40:05we live in a system that really makes
40:07it the path of greatest resistance
40:09to make the healthiest choices.
40:11And you know often the default pathway
40:14is eating unhealthy processed food not
40:17getting enough fruits and vegetables.
40:19You know, we we've come a long way
40:22with with with tobacco smoking,
40:24but you know the lack of physical
40:26activity and a lack of.
40:27Access,
40:27whether spatial or financial or
40:30educational to healthy patterns
40:32of eating is is really,
40:34I would argue another epidemic
40:36that our society is dealing with
40:38and yet we we that doesn't carry
40:41the same stigma that that patients
40:44with addict addiction often face.
40:46And so it's really important I think
40:48that you know we we understand that
40:51that just because someone is making
40:53a choice that maybe is not in their
40:56best interest that really doesn't
40:58have any bearing on our professional
41:00responsibility as physicians or
41:02as other clinicians or healthcare
41:04providers or a society really to
41:06make sure that we treat patients with
41:08both compassion and with evidence
41:10based intervention such as those
41:11that that Doctor Weimer discussed.
41:15And you know, if we are interested
41:18in talking about poor choices,
41:19then I think we would be remiss if
41:22we didn't mention the fact that the
41:23opioid addiction crisis has been
41:25largely fueled by misleading claims by
41:28both by the Pharmaceutical industry.
41:30I'm sure everyone's heard about what
41:32what's happened with the Sacklers.
41:34And you know, the fact that when
41:36you're only faced with paying fines,
41:37when you have what seemed like
41:39bottomless pits of money and there are
41:41no real consequences like jail time.
41:43It's it's kind of striking the
41:45lack of consequences that that some
41:47people face versus the the incredible
41:49consequences that result from not
41:51just the the scourge of addiction
41:53but also the stigma that exists
41:55and the often the lack of resources
41:57that it that exists to treat it.
41:59And then of course,
42:00physician over prescribing as well.
42:01You know,
42:02whether that's because physicians were
42:03also misled about the importance of
42:05of adequate pain control versus just
42:07it being the path of least resistance.
42:09When someone asks for something
42:10prescribing it that that's a little
42:11bit beyond the scope of today's talk.
42:13But I think it's important to understand
42:15that the the opioid epidemic is very
42:19multifactorial and isn't simply a
42:21product of of individual decision making.
42:24Because like I said people,
42:26people do not choose this and it's
42:29really complex how how it happens and
42:30can vary a lot between individuals.
42:34So I want to talk about
42:37first you know sort of some some
42:38justice considerations right.
42:39That's one of our kind of main
42:41principles in biomedical ethics.
42:42We talk about justice or the
42:44imperative to treat patients both
42:45rationally and fairly right.
42:47I've, I've made some comparisons
42:48with other chronic diseases and
42:50I I will continue to do so.
42:51So you know we've argued that PCI
42:54stands for percutaneous coronary
42:57intervention which is basically
42:59angioplasty and stentine for
43:00blockages in in heart arteries for
43:02the for the non medical audience or
43:05for the first year medical students
43:06who haven't had homeo basis yet.
43:08So you know we are it would be a
43:11rational to perform to stent arteries
43:13in a patient with stable angina
43:15meaning chest pain that's stable not
43:17because of you know a heart attack
43:19without providing any medical therapy
43:21to optimize their hemodynamics,
43:22meaning optimizing their blood flow,
43:24their blood pressure,
43:25their heart function and to prevent
43:27underlying disease progression
43:28or progression of the plaque.
43:30And so basically you know the there
43:32are very clear guidelines that yes,
43:33you're going to stent someone who's
43:35coming in with a heart attack.
43:37But in someone with just kind of
43:39state chronic stable chest pain it
43:41it would be really kind of silly to
43:43treat you know a focal manifestation
43:46of a systemic disease without
43:48providing systemic treatment of that
43:50disease with antiplatelet agents,
43:52anti hypertensive agents, you know,
43:55statin therapy etcetera, etcetera.
43:56And so you know similarly as
44:00Doctor Weimer said it,
44:01it would be crazy kind of it would
44:04be irrational really to perform
44:06a valve replacement for IDU i.e.
44:08without at all addressing the
44:09underlying cause of the illness with
44:11evidence based addiction treatment.
44:13So it's just it you know,
44:14I think it's helpful again because
44:16there is so much historical stigma
44:18about the treatment of addiction and
44:20a lot of I think therapeutic nihilism
44:22on on behalf of of clinicians.
44:24I think it's important to think
44:26about maybe comparable conditions
44:28in cardiology or in medicine in
44:30general to to really go through that
44:33thought experiment and and think
44:34about why why we would expect things
44:36to get better if we don't treat the
44:38underlying cause in one condition
44:39when when we wouldn't otherwise.
44:40So you know furthermore we argue
44:44that it's unjust to categorically
44:46that there may be some cases where
44:48the harm may outweigh the benefit.
44:49But just to sort of knee jerk
44:52refuse a repeat valve replacement
44:54in a patient with IDID i.e.
44:56when few people would hesitate for
44:58example to perform repeat angioplasty and
45:00stentine in patients who continue to smoke.
45:03We know smoking is a huge risk
45:05factor for coronary artery disease.
45:06But we wouldn't somehow say to someone,
45:08well, you know,
45:09your angina's back and we've got
45:11it's optimized on medications
45:12but you won't quit smoking.
45:14So you know you don't want to help yourself.
45:16So we're not going to put another stent
45:18in you that that that just doesn't happen.
45:20And you know,
45:21we we do hear sometimes about the
45:23imperative to judiciously allocate resources.
45:25But again that that resource you
45:28know that in the absence of a truly
45:31scarce resource like solid organ
45:33transplants or perhaps ventilators
45:35in you know at the peak of a COVID
45:38pandemic valve replacement isn't like
45:39that And so you know we we we don't
45:43have to ration prosthetic valves
45:45certainly it is important to weigh the
45:47risks and benefits in these patients.
45:49So it just like we shouldn't knee
45:51jerk say well you know we don't we
45:54don't do repeat valve replacement
45:56in in patients who who continue
45:58to inject drugs to it it it
46:04but it's really important to
46:05consider it on a case by case
46:07basis basically and and way that
46:08risk and benefit in in each case.
46:12So moving on to talk about some of the
46:15futility related considerations in in
46:18the in the management of endocarditis.
46:20Futility is a tough term and I know Doctor
46:23Mercurio actually talks about this in
46:26the professional responsibility course
46:29for the first year medical students.
46:30But you know the the question of futility
46:33is very fraud and often often whether
46:35or not something is futile is not
46:37something intrinsic to with the proposed
46:39intervention itself but rather related
46:41to what is the goal of that intervention.
46:43And so it's really important
46:45to keep that in mind.
46:46Furthermore,
46:46when we argue on the grounds of, you know,
46:50what we described as psychosocial futility,
46:52in this case, you know,
46:53the idea that, well,
46:54we don't want to replace the valve
46:56because we think the patient's just
46:58going to keep using drugs anyway,
47:00that that can really again be fraught with
47:02implicit bias and with value judgments.
47:04So any questions of futility
47:06should really be focused,
47:08refocused on what are the patient goals
47:10and then what are the direct risks and
47:12benefits of the intervention in question.
47:14So you know if a patient's
47:16presenting with recurrent IDU i.e.
47:18And it's complicated by valvular
47:20dysfunction with heart failure or
47:22septic emboli or persistent bacteremia,
47:25and they express the goal of short
47:27term survival and a willingness
47:29to engage in addiction treatment
47:30to address the underlying cause.
47:33It's really problematic and inaccurate
47:35to deny surgical intervention
47:36on the grounds of futility.
47:38Unless of course the risk of death
47:39or disability from the intervention
47:41itself outweighs the risk of death or
47:43disability from treating it conservatively
47:45with medical management alone.
47:48And furthermore, any claim of futility
47:50is invalid if the patients aren't
47:52offered or don't receive evidence based
47:54treatment of the underlying addiction.
47:56So again, that's like saying,
47:58you know, it's an intervention,
48:01another cardiac intervention is
48:02for coronary diseases is futile.
48:05Well, the stent didn't fix things well,
48:06you didn't prescribe them anti platelets.
48:08So yeah, they had,
48:09they had stent thrombosis.
48:11That doesn't mean that the
48:13stenting process was futile.
48:14It means that the patient's
48:17underlying conditions weren't managed
48:18appropriately and very predictably.
48:20This happened at just like very predictably.
48:23If you don't manage someone's
48:25addiction at all, they're going,
48:26they're very likely going to have a
48:29relapse that's that's to be expected.
48:31So again, addiction is a chronic illness.
48:32I know we keep all the key points.
48:35We try to repeat multiple times.
48:36Addiction is a chronic illness for
48:38which the potential for relapse
48:40must be anticipated and just as
48:42importantly must be mitigated.
48:44As Doctor Weimer said,
48:45through these outpatient programs
48:46for patients are not just started on
48:48medications but also maintained all
48:52right. So what about
48:53the concept of autonomy right?
48:54Or the right patients rights
48:56to self determination?
48:57Again, if patients express a
49:00sincere desire to recover from their
49:02endocarditis and from their addiction,
49:04they shouldn't be denied
49:05surgical or intervention that
49:07would otherwise be indicated.
49:08And that's of course in the
49:09absence of contraindications,
49:10right you you,
49:11you don't necessarily have the right
49:13to to insist upon a treatment if if
49:15the risk of that treatment clearly
49:18outweighs the benefit of that treatment.
49:20But we're talking about medical
49:22or surgical contraindications to
49:24that surgery itself, not not,
49:27not predictions of potential for relapse,
49:31again without treating the underlying cause.
49:34And then as as we heard earlier as well,
49:36patients unwilling to accept certain
49:39medical or surgical treatments,
49:41we should still offer certain treatments
49:43that they might be willing to accept
49:45and avoid this sort of all or nothing
49:48stance because there's still a lot of
49:50harm reduction that we can provide.
49:52And in addition to the mitigation of
49:55some medical complications especially
49:57for less advanced endocarditis.
49:59That being said,
50:00you know as as we've discussed
50:02autonomy doesn't mean you can do
50:03whatever you want whenever you want.
50:05And so sometimes it is necessary
50:07to set boundaries on behavior.
50:09I think another reason often that
50:11another thing that drives stigma
50:13of of patients who struggle with
50:16addiction is that by its very nature
50:19addiction is very challenging.
50:21It it and it's alterations of brain
50:24chemistry and just the absolute
50:29just the how, how difficult it
50:30can be and how how just painful,
50:32viscerally challenging it
50:33can be to be in withdrawal.
50:35Patients often may result to to
50:38desperate means to just alleviate
50:40those symptoms and to to feel normal.
50:43And so you know if a,
50:45if a patient has someone who's
50:47coming into the hospital and
50:48bringing drug paraphernalia,
50:50it's OK to set a boundary and say
50:52the this person can't visit if
50:54they clearly have demonstrated
50:56that they are on that they're
50:58continuing to actively impede
50:59the proper care of the patient.
51:01But at the same time often they're because
51:05being in the hospital for patients
51:07is a time where patients often feel
51:09like they aren't in control as much.
51:12And and that's not just a feeling.
51:13I think that's also true, right.
51:14When you're in the hospital you you don't
51:16have as much control as you normally would.
51:19I I think it's very natural for
51:21patients to seek as much control
51:23as possible and I think often
51:25overwhelmed floor staff or unit staff
51:27can feel like they need to assert
51:29control and often we can see sort of
51:32this devolving battle for control.
51:34So it's it's really,
51:35really important that when boundaries
51:36are set that they're that they're
51:39clearly articulated in the rationale
51:40and their scope and that they're
51:42limited simply to protective measures
51:44and and it's really important to avoid
51:46sort of punitive intent or just to
51:47set a boundary to show well that's
51:49because I said so because we're in
51:51charge and we're going to say how it goes.
51:53And so it's it's really important
51:55to to be firm with boundaries
51:57but to also understand what the,
51:59what the point of those boundaries is
52:01and that you know it it avoiding that
52:04sort of control power struggle that I
52:07think sometimes we we've seen happen.
52:09So that's an important consideration.
52:11So we heard about some of the
52:14updated guidelines that I'm going
52:16to go through briefly.
52:18So in 2020,
52:19the ACAHA guidelines were updated to
52:22include recommendations about IDUID
52:24which were absent from earlier guidelines.
52:26And basically it just very importantly,
52:28these guidelines recommended consultation
52:30with addiction medicine to discuss the
52:32long term prognosis for the patients,
52:34refraining from actions that risk
52:36reinfection before repeat surgical
52:38intervention is considered.
52:39So again underscoring the critical
52:41importance of addiction medicine
52:42to treat the underlying cost.
52:44As we've heard beyond prognostication,
52:46addiction medicine specialist can
52:47offer treatment that may reduce the
52:49likelihood of recurrent use by as
52:51much as 50% and not just recurrent
52:53use but also all 'cause mortality.
52:55As as we've heard And so in the scientific
52:58statement that we already heard about,
52:59I just I think this this piece
53:02is really important here.
53:03A detailed discussion with the
53:04patient and the endocarditis team is
53:06warranted about the surgical risks
53:08and prognosis among those deemed
53:09candidates for repeat valve surgery.
53:11Just as it is for people with
53:12IEEE who do not inject drugs,
53:14proceeding with another operation
53:15requires a plan for treatment of
53:18the addiction supported by addiction
53:19trained clinicians and as a team decision.
53:22So it's a critical addition.
53:24And so you know we think of this as sort
53:26of a a stepwise framework for approaching
53:28these often very complex patients.
53:30The first step is just like with
53:33other proposed medical interventions,
53:35we consider the medical and surgical
53:36risks and benefits in determining whether
53:38surgical intervention is likely to
53:40improve the patient's short term outcome.
53:42The short term outcome not not invoking
53:45potential for quote futility later on.
53:48And then the next step is to consider how
53:51best to manage the patient's addiction in
53:53order to optimize those long term outcomes.
53:55And that's where again our addiction
53:57medicine colleagues come in And
53:59rather than setting some absolute
54:00number of RE operations that should
54:02be considered acceptable,
54:03once again,
54:03you know this really critical concept
54:05that we hear in in medicine and
54:07medical ethics all the time is we we
54:09need to balance the risks versus the
54:11benefits in each individual case as
54:13the most important consideration.
54:14And I should say not just the risks
54:17and benefits as far as medical
54:19facts are concerned,
54:20but also take into account the
54:23patient's priorities, goals and values.
54:25Because again these these patients
54:27are often struggling with very
54:29complex social situations.
54:31And so it's easy I think for us sometimes
54:34as clinicians to have blinders on
54:36and be hyper focused on the medical
54:38facts which are incredibly important.
54:40But we also need to consider the
54:42patient priorities and what might be a
54:44burden to patients might not seem like
54:46such a burden to us and vice versa.
54:48So it's important to sort of consider
54:51that not everyone's weighing of risks
54:52and benefits may may be the same
54:55depending on their circumstances.
54:56So just to summarize some of the
54:58key points or what we'll call the
55:00medical and ethical best practices
55:02in the management of these patients.
55:04Worth noting that in a 2016 study
55:07which now is not,
55:08you know again not that long ago,
55:10although I think the field has really
55:11advanced by leaps and bounds since then.
55:13But in 2016 only 24% of patients
55:16presenting with IDU i.e.
55:18received inpatient addiction medicine
55:20consultation and addiction was
55:22mentioned at only 56% of the discharge
55:24summaries for these patients.
55:25So lots, lots of progress to be made,
55:28although I think we have made quite
55:30a bit of progress.
55:31The medical team has an obligation
55:33to provide evidence based addiction
55:34care just as we have an obligation to
55:36provide evidence based care in general
55:38to patients when they come to us.
55:40And the health system furthermore
55:41has an obligation, we would argue,
55:43to ensure adequate mechanisms and
55:45pathways to ensure robust transition
55:46to outpatient treatment.
55:48And social support as as we've heard,
55:49is so important for for sustained
55:53treatment of a chronic disease,
55:56until patients have initiated treatment,
55:59it can be really difficult to predict the
56:00likelihood of substance use occurrence.
56:01So we should avoid making vague
56:04predictions and generalizations because
56:05of what we assume is a foregone conclusion.
56:08Avoiding assumptions in general
56:09is is good practice in medicine,
56:11although again we we tend to take
56:14a lot of cognitive shortcuts and
56:16so just being mindful of of the
56:19assumptions we might be tempted to make.
56:21And then finally patients
56:23presenting with recurrent IDU i.e.
56:24Should be evaluated by a
56:26multidisciplinary team,
56:27ideally including addiction medic
56:29medicine specialists, ID specialists,
56:31infectious disease specialists,
56:32cardiac surgeons, cardiologists,
56:34hospitals, nurses,
56:35social workers and and really any
56:38anyone else who can provide both
56:41their expertise and and their
56:43compassion in treating these very
56:45complex and vulnerable patients who
56:47again deserve compassion and care
56:49just as all of our patients do.
56:51Thank you very much.
56:59Thank you so much, Sarah.
57:01I wonder if there's a way
57:04to turn up some lights up here
57:06so we can get a see our speakers
57:08as we start asking questions.
57:10I don't see the this has changed
57:13since the last time I drove it.
57:16I'm here. I don't know if you
57:17know how we can bring the lights
57:19up on this thing or if we can.
57:21OK, say it again.
57:21So we can't really bring it up on this.
57:23I can watch with the lights,
57:24but it's almost guarantee you
57:27just want to dim the lights in
57:28the whole bit And here you go to,
57:31oh, it's over here. All right.
57:31There we go.
57:32I want to give you this.
57:33This is for the chat.
57:33If
57:35if we can also just pull chairs
57:36up here, there's a little bit more
57:37light there and grab the mic.
57:38Would that be better if
57:40that's the best option we have.
57:42And the chat, the people aren't
57:43coming in on chat. I mean,
57:44they're coming in on Q&amp;A. What?
57:49So we we're going to do a
57:51couple different things here.
57:52One is I need to see the the Q&amp;A portion.
57:57The other is for the folks in the audience.
57:59Please wait until the someone brings
58:01you a microphone if you have a question
58:03so that the folks on Zoom can hear.
58:04OK, that's perfect. Thank you so much.
58:06And I'm going to thank you 2 for what was.
58:10Yeah, that's better. Oh, oh, there we go.
58:13Now we're lit up. Now we're lit up.
58:16So something for everyone.
58:18It's a little something for the students
58:21and perhaps others in the owner.
58:23It's just a couple words about
58:24culture and something that you guys
58:26may remember that we talked about
58:28in the course a couple months ago.
58:30It's been a long time since I
58:31was on an adult medical service.
58:32I was an intern on adult medical
58:34service during the grant administration.
58:36And at the time there was,
58:39there was a culture and I and I,
58:41and it's fascinating to me here,
58:42is that I suspected some of this
58:45culture persists and the culture
58:47was a culture of resentment to
58:50people who used illegal drugs.
58:53And and that resentment I think
58:57clearly affected among many of
58:59us the way they were treated,
59:01the way they were spoken about
59:03and the way we considered.
59:04And so I appreciated the analogy
59:06that you drew with heart disease,
59:08with other heart disease related to
59:10smoking or related to other lifestyle
59:15choices or other aspects of lifestyle.
59:17I mean, I think that's important.
59:19Remember, we talked about when
59:20you see somebody, when you get to
59:22justice and we talk about equality,
59:23say when you see somebody being
59:25treated as something less,
59:26you have to ask yourself why that might be.
59:28And you got, of course,
59:29importantly as physicians,
59:30we got to ask ourselves,
59:31am I actually taking part in that?
59:33Is there something different about
59:35people who use intravenous drugs,
59:37illicit drugs, illegal drugs,
59:39heroin, whatever we want to talk
59:40about whatever term we want to use?
59:42Is there something about the way
59:43we approach these folks that is
59:45inherently different and unfair?
59:48And so I think that you both gave us
59:49a lot to think about in that regard.
59:53It's about the culture and it's about
59:55seeing a group of people who are
59:58treated as something less and and
60:00sometimes blamed for their misfortune.
01:00:02That said, I I want to talk about a
01:00:05specific example that you raced, Melissa,
01:00:07in the case of the surgeon in Knoxville.
01:00:10Who decided that he wasn't
01:00:12going to fix the valve again,
01:00:13replace the valve again.
01:00:15And that was the most difficult
01:00:16decision I ever had to made make.
01:00:18And that wasn't that long ago.
01:00:19I don't think that case that you
01:00:22described 2018. Yeah.
01:00:25And so the my question about that
01:00:27case and you might know or or if you
01:00:29want to comment on this in general,
01:00:31is one thing that fascinated me was,
01:00:34and I see this from time to time,
01:00:35that did that individual surgeon,
01:00:37you actually get to make the decision.
01:00:39I get it that an individual surgeon
01:00:40may be able to make the decision,
01:00:42I'm not going to do this.
01:00:44But of course what I'd be wondering
01:00:45if I got my medical ethics hat
01:00:47on is what was the patient made
01:00:49aware of what his options were?
01:00:50Was there somebody else in
01:00:51the hospital could do it?
01:00:52Was there another hospital 1/2 an hour
01:00:53down the road that would have done it?
01:00:55You know how much of this was done.
01:00:56But are these decisions which I
01:00:58take it are still sometimes made,
01:01:01which is to say not to do
01:01:03a repeat valve replacement.
01:01:04Are these decisions commonly
01:01:06made by an individual clinician?
01:01:09How often is is, are other groups involved?
01:01:12And it's very end Sarah,
01:01:13you you spoke about the various
01:01:15team you wanted involved,
01:01:17but if there's a decision not to give
01:01:19someone a potentially life saving treatment,
01:01:22it fascinates me to wonder who makes
01:01:24that decision and does the patient
01:01:26know what their other options are?
01:01:27That by the way,
01:01:28we won't do it here.
01:01:28They might do it,
01:01:29you know at Columbia or in Boston
01:01:31or at Hartford or whatever.
01:01:36Well, I I can tell you that you know in past,
01:01:39yes, it's been an individual person
01:01:41and I I've been on both sides.
01:01:44I've been on the pre multidisciplinary
01:01:46team side and I now that we
01:01:48have a multidisciplinary team,
01:01:50I think it's improved.
01:01:52But historically, yes,
01:01:53it's been up to an individual
01:01:55person to make a decision.
01:01:57I think, you know,
01:01:59teams might invoke an ethical
01:02:01consult or maybe they would they
01:02:04would ask for for an ethics consult.
01:02:07But I think that's why teams
01:02:09like the multidisciplinary
01:02:11endocarditis team are so important,
01:02:12so that we can talk about what's going
01:02:17on and really flesh out implicit
01:02:20explicit bias and all the medical,
01:02:23surgical complications.
01:02:24And what I've seen through the
01:02:28evolution of my career is that there's
01:02:32a lot of experiences that can come
01:02:35from all of us meeting together,
01:02:38where I learn a lot from the surgeons.
01:02:41I know more about cardiac surgery
01:02:46than I know about diabetes care,
01:02:49right?
01:02:49Like I can talk to my patients about exactly
01:02:52what's going to happen when they're in,
01:02:54you know,
01:02:55having their cardiac surgery because I'm
01:02:57seeing the patients like right after,
01:02:59I'm talking to the surgeon
01:03:01right after the surgery.
01:03:03So all to say that I think there's
01:03:05so much value of the face to face
01:03:08conversation and unfortunately
01:03:10sometimes some of these life or death
01:03:13decisions were basically being made in
01:03:17a chart note without any conversation.
01:03:20And so you couldn't know like why
01:03:23is the surgeon saying this isn't.
01:03:25I don't want to proceed with this
01:03:27surgery and what I've what I've
01:03:28come to know is that most of the
01:03:30time that they're saying no,
01:03:31it's it's for a really you know,
01:03:36specific reason.
01:03:37So I don't know, Sarah,
01:03:38if you want to talk about your
01:03:40experience or if you think we do this.
01:03:42Well,
01:03:42I don't want to make it sound like
01:03:44we never have conflict because
01:03:45we certainly have conflict.
01:03:46And we sometimes ask for second
01:03:49opinions or we sometimes say,
01:03:50you know,
01:03:51somebody should consider going
01:03:53to another institution and we
01:03:55have had patients leave to,
01:03:56to try to go to other institutions.
01:03:59I would say our institution
01:04:00is actually quite liberal.
01:04:02And so it doesn't happen that often anymore,
01:04:05but it certainly happened before.
01:04:08Yeah,
01:04:08I I would. I would tend to agree with that.
01:04:12You know thinking about my
01:04:14experience as a fellow which was
01:04:17you know as over 10 years ago,
01:04:19I guess I finished 1010 years ago.
01:04:22The approach was very
01:04:23different than than it is now.
01:04:25And I actually remember
01:04:27being involved as this.
01:04:28This is how I sort of first became
01:04:30introduced to this area where I was
01:04:33on a a cardiology consult team with a
01:04:36patient in this in in a situation like
01:04:38this where he had already had surgery,
01:04:41he had recurrent IDU i.e.
01:04:45And two surgeons had actually
01:04:47declined to operate and then
01:04:48an ethics consult was called.
01:04:50And then ultimately,
01:04:53you know, basically they,
01:04:55they said sort of you know,
01:04:57along the lines of what what we said that,
01:04:59you know if there's not,
01:05:01if there's not an absolute,
01:05:03you know,
01:05:04if the risk benefit ratio would normally
01:05:06favor surgical management of this disease,
01:05:08then you know,
01:05:09it shouldn't be declined just because of
01:05:12the risk of of substance use recurrence.
01:05:15And so someone did actually
01:05:18provide that surgery,
01:05:19but it's unclear whether he was
01:05:21actually hooked up well with
01:05:22addiction medicine treatment.
01:05:24And so he did come back and so that
01:05:27that was that was kind of what happened.
01:05:29And so,
01:05:30yeah,
01:05:30I mean the the our discussions in the
01:05:33multidisciplinary team often are you know,
01:05:35we don't necessarily always have
01:05:37consensus and they often are messy.
01:05:39But I I mean I think that's
01:05:41that actually is a positive.
01:05:42If everyone always agreed on everything
01:05:44that means that probably there
01:05:45aren't enough diverse perspectives
01:05:47represented because these cases
01:05:48aren't always easy and it's not
01:05:50like Oh well automatically OK,
01:05:52someone has bad endocarditis,
01:05:53we're going to do surgery.
01:05:55I I agree that typically that is the
01:05:58route that we try to go when it's indicated.
01:06:00But there are cases where patients,
01:06:02if patients are just not willing and and
01:06:05not able to engage in a plan for treatment,
01:06:08we realized that sometimes we
01:06:10can leave patients worse off
01:06:11if if we perform a surgery.
01:06:13So it's not there's not A1 size
01:06:15fits all approach to these patients.
01:06:18But yeah,
01:06:19I I think it's it,
01:06:20it's definitely gotten better
01:06:21but it's still a very challenging
01:06:23population to care for.
01:06:25OK. We got a few people already
01:06:27who want to has questions.
01:06:28So we're going to start with one
01:06:31with Doctor Tolson 2 and three.
01:06:32Let's start first with Ben.
01:06:34Thanks. So, so great talk.
01:06:36I I really appreciate the points
01:06:37particularly that you know patients
01:06:39must have access to addiction medicine
01:06:42treatment and and two that that that
01:06:48bias needs to be put aside at the
01:06:53same time you know so so we we had a
01:06:58recent ethics consultation around a
01:07:00very difficult case of a patient who
01:07:02had received full addiction medicine
01:07:07services and you know in that in that
01:07:11case the patient eventually decided
01:07:12that she didn't want the treatment
01:07:14and and so there was consensus and and
01:07:16and there was no disagreement but I
01:07:19could imagine that that having gone a
01:07:22very different way and I can imagine
01:07:24an argument based not on bias not
01:07:27on stigma but on life expectancy for
01:07:32severe opiate use disorder that has
01:07:35been refractory to treatment through
01:07:37multiple rounds of prior endocarditis.
01:07:40The argument being that the patient
01:07:43has a six month life expectancy.
01:07:46We wouldn't offer the surgery to
01:07:49somebody with advanced cancer had
01:07:51a life expectancy in that range.
01:07:54So we similarly not because of the
01:07:56kind of chronic illness that she has,
01:07:59but because she has a chronic life
01:08:01limiting illness with a six month
01:08:03life expectancy.
01:08:03We should not be offering surgery.
01:08:06We we we avoided
01:08:07that whole debate in this case.
01:08:09But, but I could very well imagine it a
01:08:11case where the patient very much would
01:08:13want surgery and we would not offer
01:08:15it based on that kind of rationale.
01:08:18I'm, I'm curious how,
01:08:19how you would approach a case like that
01:08:21where the patient was very much saying,
01:08:23I will do treatment,
01:08:25I want the surgery and.
01:08:27And what would you do then?
01:08:31It it, I mean it it to to.
01:08:33Yeah, right there, please.
01:08:35Next, I mean, I would add to that a bit,
01:08:37'cause I think it's a great question,
01:08:38Ben, is that is there some threshold
01:08:39that we reach where we say,
01:08:41yeah, we're we we as a hospital
01:08:42are willing to do the surgery,
01:08:44but do we reach a threshold perhaps
01:08:46based on prognosis for survival
01:08:47where we say we're at a point now
01:08:49where we no longer make it available.
01:08:53So unfortunately, that's not an
01:08:55uncommon situation that we encounter.
01:08:58I can say one one thing that's been really
01:09:02interesting as well is that we get to
01:09:05know these patients really well, right.
01:09:08They're in the hospital for a very long time.
01:09:11Our team sees them daily.
01:09:14We get to know their family,
01:09:15we get to know them,
01:09:17we get to know lots of things about them.
01:09:20So I think though we're
01:09:23not outpatient clinicians,
01:09:24we're not seeing them outside the hospital.
01:09:26We might know them better than
01:09:29anyone outside the hospital, right.
01:09:31And sometimes and in particular the
01:09:33patient that you were mentioning,
01:09:36we were her thread.
01:09:38We were the clinicians,
01:09:40the addiction medicine team who was
01:09:42treating her for the last two years,
01:09:45not anyone outside the hospital.
01:09:48So you know I think it's an opportunity
01:09:52for us to talk with the patient,
01:09:54really provide some hard information to
01:09:57them to say I hear what you're saying,
01:10:02you want everything done for you.
01:10:05Let's talk about how things have
01:10:08been going and just recognize the
01:10:12discrepancy and just really helping
01:10:14them work through that discrepancy
01:10:16and how we can best treat them
01:10:18and and they they are going to
01:10:21have to walk through some take
01:10:23some real difficult steps forward.
01:10:25And in that case that you discussed
01:10:28like I was not in favor of that patient
01:10:31having surgery because I knew how
01:10:34incredibly challenging it would be for her.
01:10:36I knew how much pain she would have.
01:10:38I knew that we would not be able to
01:10:41give her enough opioids to treat her
01:10:43pain or non opioids or anything.
01:10:45So I think that perspectives helps,
01:10:49but these are heart wrenching situations.
01:10:54These are young people.
01:10:56These are people less than 40 years of
01:11:00age and they are dying with young kids.
01:11:03I mean it's heart wrenching and I remember,
01:11:07you know,
01:11:08all of these cases I remember and
01:11:11they really profoundly affect me.
01:11:14So I I don't know.
01:11:15It's hard to say every single
01:11:17case because every single case
01:11:19is so individualized.
01:11:21But.
01:11:22But we do have to have some hard
01:11:25conversations sometimes.
01:11:26And and yes, addiction treatment works,
01:11:28but sometimes it doesn't.
01:11:32Can we have Here is next,
01:11:34please. Yeah. Doctor
01:11:35Hole, you mentioned sort
01:11:37of a distinction. Hold
01:11:38it a little closer, please. Oh, isn't it? Oh,
01:11:41it's on. OK. You mentioned a
01:11:44distinction of prosthetic valves.
01:11:46Unlike solid organs like not
01:11:48being a scarce resource,
01:11:50I'm curious if I if I I VDU related,
01:11:56whatever if I gotcha.
01:11:57If it ever gets bad enough that like a
01:12:00full heart transplant is required and
01:12:01if so do your ethical considerations
01:12:04change related to this that that
01:12:08is a great question.
01:12:10You know, I I don't ever recall
01:12:13a case where that happened.
01:12:17You know, I so
01:12:19you know, usually a heart transplant is
01:12:21something that's considered for someone
01:12:23who has you know end stage heart failure
01:12:25that's refractory to other measures.
01:12:27And so you know the criteria for solid
01:12:31organ transplant are pretty strict.
01:12:33Sometimes there can be some variability
01:12:34but for example abstinence from
01:12:36smoking is required. So I, I, I'm,
01:12:39I'm speaking in in theory because again,
01:12:42I have not encountered this.
01:12:44But you know if if you required six months
01:12:46of abstinence from smoking, you know,
01:12:49I, I I can't imagine a scenario where
01:12:52you wouldn't want to see six months
01:12:55of abstinence from from IV drug use.
01:12:58You know, again not not in a punitive
01:13:01way but simply in a maximizing the
01:13:03utility of a very scarce resource way.
01:13:05Although again that can be very
01:13:07ethically fraud Like that is not a
01:13:09straightforward calculus in all cases
01:13:11because again you know when when
01:13:12you stricter you make the criteria,
01:13:14the more likely you are to marginalized
01:13:16already vulnerable population.
01:13:17So I.
01:13:17So I recognize that it's not Oh
01:13:18well that's easy like just you know
01:13:20handle that what is the right time?
01:13:21Is 6 months the right amount of
01:13:23time Like is it should it be longer.
01:13:24And so it's it's a difficult conversation.
01:13:28You know there,
01:13:29there are other therapies for end stage
01:13:32heart failure besides transplant like
01:13:35inotropic therapy like IV inotropic
01:13:38therapy and left ventricular cyst devices.
01:13:41Again I I can't imagine that that an
01:13:43LVAD or left ventricular cyst device
01:13:46that's that's very prone to you know
01:13:48that's another huge foreign body.
01:13:50So the issue of infection would
01:13:51would be a a big issue and I I can't
01:13:54say I've ever seen that either.
01:13:56And so again I'm this is all in
01:13:59theory but usually you know valvular
01:14:02disease if if treated early enough
01:14:04hopefully you can prevent heart failure
01:14:06from happening and even if you do
01:14:08develop heart failure from that there
01:14:10often are a lot of really effective
01:14:12medical therapies to reverse it.
01:14:13But in theory could you know long standing
01:14:15valvular disease lead to heart failure?
01:14:17Absolutely.
01:14:18In fact an an older practice was you know
01:14:23the the the right ventricle gets no love.
01:14:26Well some some of the the cardiologists
01:14:28in the audience can can appreciate that.
01:14:30But you know the the the left
01:14:31ventricle as you like,
01:14:32that's the main pumping Chamber of the
01:14:34heart that pumps blood through the body.
01:14:36The right ventricle pumps blood
01:14:37into the lungs.
01:14:38It doesn't have to generate
01:14:39as high a pressure.
01:14:40So you know one of the valves that
01:14:43that controls blood flow between the
01:14:45right atrium and the right ventricle,
01:14:48the tricuspid valve,
01:14:49is often in one of the first to be
01:14:51infected with injection drug use.
01:14:53And an old practice was to simply remove
01:14:55that valve and not put anything back
01:14:56if it was infected with endocarditis
01:14:58because the the thinking was,
01:15:00well if there's not a valve there
01:15:01to be infected then that's,
01:15:03you know, then patients are less
01:15:05at risk of developing recurrent
01:15:07endocarditis and you don't really
01:15:08need your tricuspid valve that much
01:15:10because it's a lower pressure system.
01:15:11So yeah you can get a little bit of
01:15:13congestion but it's not a big deal.
01:15:14But actually that's you know that's
01:15:15not that's not really accurate and
01:15:17and you do need a tricuspid valve
01:15:19and right sided heart failure is a
01:15:21very real problematic entity and and
01:15:23so that that's it's not that that is
01:15:25an impossible consideration but I I
01:15:28think typically I I have not seen a
01:15:31case like that and and I think there
01:15:33would be pretty stringent criteria
01:15:36beyond simply the individual risk
01:15:38benefit ratio for that patient but
01:15:41also criteria to make sure that that an
01:15:44organ transplant is being get offered
01:15:46to someone who will be able to be a
01:15:48steward of of that scarce resource.
01:15:49And I and I think that is fundamentally
01:15:51different from something like a valve
01:15:53replacement and people will argue
01:15:55well you know we practice medicine
01:15:56in the US as if we had unlimited
01:15:58resources and and you know that that
01:16:00is true sometimes unfortunately and
01:16:02and that that has problems of its own
01:16:06right because you know things like
01:16:08prenatal care and vaccinations like
01:16:09those we we should be crushing it
01:16:11and we are not crushing it on that.
01:16:13But,
01:16:13but is it really like
01:16:15is it the is
01:16:18it's it's hard to take a leap from that to
01:16:19saying well then we shouldn't do as many
01:16:21valve replacements because like people
01:16:22aren't getting up prenatal care like those,
01:16:24those those are separate issues.
01:16:25And you know if we want to talk about how we,
01:16:27you know allocate healthcare,
01:16:29how we ration healthcare because I've
01:16:31argued like ration is a dirty word in
01:16:32in the US like we don't ration care.
01:16:34Like we do ration care,
01:16:36we ration care on based on
01:16:38patient's ability to pay.
01:16:39But I think that's really conflating
01:16:4211 problem with another problem.
01:16:44And it's important not to sort of
01:16:46like sublimate our frustration
01:16:48with patients into you know into
01:16:51discussions about like are we using
01:16:53resources as as best we could.
01:16:55But again, a,
01:16:56a solid organ transplant is different because
01:16:59when you offer an organ to one patient,
01:17:00that's there's another patient
01:17:01who's not getting that organ.
01:17:03And so that does change the
01:17:04calculus a little bit.
01:17:06So I want to, I want to get to a couple
01:17:09more questions before we're done.
01:17:11The gentleman in the scarf and then the
01:17:12gentleman in the back in the black coat
01:17:14and then the lady here in the blue jacket.
01:17:16I want to try and get to all three within.
01:17:17We got about 10 minutes left.
01:17:18Go ahead, please.
01:17:19Thank you. And this briefly,
01:17:21are you just with the whole the
01:17:23multidisciplinary approach and you mentioned,
01:17:25you know, the utility of having addiction
01:17:27consult program as part of like the
01:17:29way the health system addresses this issue.
01:17:31Are you finding that just from an
01:17:34infectious disease perspective,
01:17:35initiating conversations like
01:17:36this or helping other systems,
01:17:38it may not be as far along as,
01:17:40you know, places like Yale and you know,
01:17:44other locations that do this
01:17:45because you know, some,
01:17:47some hospitals don't even have addiction
01:17:48consult services and then they don't
01:17:50know what to do with patients like this.
01:17:51So they may be forced to this problem,
01:17:53you know,
01:17:53at a higher extent.
01:17:56Yeah, I mean I I think it's kind of raising
01:17:59the the standard of care. So you know,
01:18:03addiction consult services cost money.
01:18:05It costs money to hire, you know,
01:18:07a physician who has this expertise
01:18:09or to to train people up to do it.
01:18:12There are definitely models that can
01:18:14be adapted that are less expensive.
01:18:17So maybe training hospitalists to
01:18:19have this expertise or if you have
01:18:21a psychiatric consult service,
01:18:24maybe having those psychiatrists
01:18:26provide the addiction care,
01:18:27which is the model in in many places.
01:18:29So they're definitely different
01:18:32models of care that can be provided.
01:18:36As far as having a multidisciplinary group,
01:18:39I think, I think it,
01:18:42you know, it was funny.
01:18:44Before I came to Yale,
01:18:45the first people who reached
01:18:47out to me I hadn't even started
01:18:49were the cardiac surgeons.
01:18:50They sent me an e-mail and they said,
01:18:52we're so excited you're coming.
01:18:54They wanted to meet with me
01:18:56before I even started my job.
01:18:59Arnor Gerson, who's not here anymore,
01:19:01but, you know,
01:19:01he was one of the first people I met.
01:19:04He said, we want you here.
01:19:06We need your help.
01:19:07So I think if if you know it doesn't have
01:19:11to be a addiction medicine specialist,
01:19:14but somebody with addiction expertise,
01:19:16if they can partner with the cardiac surgeon.
01:19:18I think the cardiac surgeons
01:19:20are asking for this help.
01:19:21I think if you went to any cardiac
01:19:23surgeon they would say, yeah,
01:19:24I have no idea what to do, I need help.
01:19:28So there certainly are systems
01:19:30around the nation to to provide
01:19:33teleconsult or other expertise
01:19:35even in places that don't have it.
01:19:38But I think it's I think we
01:19:39need our cardiac surgeons,
01:19:41our cardiologists to say just like you
01:19:43know the doctor Pollard in Knoxville,
01:19:46TN.
01:19:46I need this care in my hospital
01:19:49to do a good job.
01:19:51So I think people need to
01:19:53start requiring this of their
01:19:55health systems. Thank
01:19:57you. Speaking of cardiac surgeons, Dr.
01:19:59Thompson. Yeah, so Mark and I go way back,
01:20:04but never mind that Doctor Thompson.
01:20:12I I retired from practice a couple years ago,
01:20:14and one of the last heart transplants we
01:20:17did before I retired was in a patient with
01:20:20complex endocarditis that had destroyed
01:20:24the the fibrous skeleton of the heart.
01:20:27So there was no there was
01:20:28no way to reconstruct it.
01:20:30It just destroyed the aorta vitral
01:20:32curtain and the only way the only way
01:20:35to get out of this problem was going to
01:20:37be to do a transplant and and we and
01:20:42we did and and the patient did fine.
01:20:45Now that that patient would have
01:20:47been turned down if they if that
01:20:51endocarditis was due to IV drug use.
01:20:53So why is that why is that ethical
01:20:58to to make that decision and and and
01:21:02I can tell you that the patient I
01:21:04remember the patient came in sick so
01:21:06we didn't have the I mean he came in
01:21:09desperately I'll so we didn't have
01:21:11we didn't have a chance to really
01:21:13do it you know to do it the the
01:21:16usual careful evaluation of of how
01:21:18responsible they were So so we don't
01:21:20really know that this guy is going
01:21:22to have is going to have this hard
01:21:25and is going to be compliant but we
01:21:27did we did that we did the operation
01:21:30and he did fine but say say he was
01:21:32non compliant Why would it be ethical
01:21:34to say just because it's IV drug
01:21:38abuse that you can't do a transplant.
01:21:43Well again I I think it's that's a
01:21:47really complex scenario and I don't
01:21:49think there's a neat clear cut like
01:21:52well this is definitely ethical.
01:21:54This is definitely not ethical as you
01:21:56identified it's you know you have you
01:21:58have competing and moral imperatives
01:22:00you have the imperative to provide
01:22:01the best care to the patient in front.
01:22:03Of you. But you know there's also the
01:22:06imperative to make sure that an organ
01:22:09that that our medical resources scarce
01:22:11the solid organs is is going to be
01:22:14distributed in in a way that is is fair
01:22:17and also and also maximizes utility.
01:22:20So you know I I I I think as as unsatisfying
01:22:25as this answer is I you know I I think
01:22:27it's going to be very context dependent.
01:22:29And I think in the apps you know you you
01:22:31have to take the information that you have.
01:22:33What context can you glean,
01:22:35what is what kind of social
01:22:37support does the patient have.
01:22:38You know with the information that you have
01:22:42you know is is this patient going to do,
01:22:45do we reasonably think this
01:22:47patient would be able to engage in
01:22:50addiction and addiction treatment.
01:22:51You know that that's that's sort
01:22:54of my my ethical answer to that.
01:22:56You know, in terms of the procedural answer,
01:22:58I'm, I'm not actually sure you know
01:23:00whether UNOS has a strict rule about that,
01:23:02whether that would be automatically
01:23:04disqualifying or whether it would be
01:23:06contextual on a case by case basis.
01:23:08But I think that you know I,
01:23:12I,
01:23:12I due diligence to whatever extent
01:23:15possible would need to happen just as
01:23:18it does with with organ transplants
01:23:20and anyone to you know ensure that
01:23:22someone's going to be able to care
01:23:24for the organ that they receive.
01:23:25Because it involves a lot of as as you
01:23:28know it involves really close follow
01:23:30up a really complex regimen of of
01:23:33immunosuppressive medication to prevent
01:23:34rejection in addition to everything else.
01:23:37And so I I think you know,
01:23:39categorical green lights or categorical
01:23:41denial is often unhelpful and
01:23:43really understanding a patient's
01:23:45context and you know in a case
01:23:47by case basis is is critical in,
01:23:49in this type of scenario.
01:23:52OK. The last question in the
01:23:53evening and I apologize to those,
01:23:54I know a lot of folks have stuff
01:23:56they want to say and I apologize
01:23:57to our friends on the line,
01:23:59but we're just going to have one
01:24:00more question for tonight, please.
01:24:02Hi, thank you so much for your talk.
01:24:04So in liver transplantation,
01:24:07they're sort of a similar dichotomy
01:24:10where many institutions require
01:24:13a six month period of sobriety
01:24:15and like quote UN quote active
01:24:17recovery prior to liver transplant.
01:24:19And in 2019, there was a Hopkins
01:24:21study that showed that the rates of
01:24:24relapse and that the rates of bad
01:24:26outcomes following liver transplant
01:24:27were no different in patients that
01:24:29had the six month sobriety and active
01:24:31recovery period for alcohol related
01:24:33hepatitis and patients who didn't.
01:24:36And there's also been similar
01:24:37studies published in Europe that were
01:24:39published in the New England Journal.
01:24:40But we still see so many institutions
01:24:44today that have not adopted
01:24:46these updated practices
01:24:48based on the evidence.
01:24:50So obviously across medicine there's a lot
01:24:52of evidence based findings that
01:24:55never quite get integrated into
01:24:57clinical practice. But like
01:24:58how do we get institutions
01:25:00to see these research findings and see,
01:25:04you know, what's happening here and
01:25:05actually adopt those things and use
01:25:08the evidence to overcome the stigma?
01:25:13Well, I was going to bring that up,
01:25:15but you did. So, thank you.
01:25:19Yeah, it's hard medicine moves
01:25:22slowly and addiction treatment in
01:25:24and of itself or addiction in and of
01:25:27itself is siloed within medicine,
01:25:28I would say and has its own amount of stigma.
01:25:34So I think we just need to
01:25:36normalize the conversation.
01:25:37We need to have conversations like
01:25:39we're having now and talk about the
01:25:42talk about these hard questions.
01:25:44Ask these hard questions,
01:25:47elevate the knowledge about
01:25:49addiction being treatable,
01:25:51elevate the options that patients are
01:25:54able to access evidence based treatments.
01:25:57Speaking of alcohol use disorder,
01:25:58you know, I said you know,
01:26:01less than 11% of people got
01:26:02opioid use disorder treatment,
01:26:04less than 2% of people with alcohol use
01:26:07disorder get evidence based treatment.
01:26:10Why? You know, like these are safe,
01:26:12effective medications,
01:26:13safer and more effective than many other
01:26:16medicines that we have than statins,
01:26:18way more effective than statins,
01:26:21more effective than antidepressants,
01:26:23more effective than venous thrombosis,
01:26:26Prophylaxis like more effective than those
01:26:30three things which we use all the time.
01:26:33So you know,
01:26:34but when's the last time you
01:26:36offered naltrexone to somebody
01:26:37with alcohol use disorder?
01:26:39Hopefully it was today.
01:26:41For me it was let's
01:26:43just go with that.
01:26:44Let's go with that. It was today
01:26:45anyway. So these are hard questions.
01:26:48Change in medicine takes time.
01:26:50We need to elevate the conversation
01:26:52and open up these these ask these
01:26:54hard questions of our health systems
01:26:56and get our health systems to
01:26:58support having addiction treatment
01:27:00or integrated addiction treatment.
01:27:02Thank you very much.
01:27:03Please join me in thanking Dr.
01:27:05Holland, Doctor Weimer.
01:27:11That's it for tonight.
01:27:12Thanks so much.
01:27:13We're going to send out a note
01:27:15tomorrow about the next one,
01:27:16and we'll see you soon.