In-hospital counselling can save lives of opioid heart patients in London
Injection drug users account for a high number of heart surgery patients in London.
Cardiac surgeons in London, Ont., are facing an unusually high number of patients with endocarditis, an infection of their heart valves, related to the injection drug use of opioids. The problem prompted scientists at the Lawson Health Research Institute and Western University to look at how to best treat the patients and improve their chances of survival.
"In London, basically 55 per cent of all the cases of endocarditis are associated with injection drug use, markedly higher than what's seen elsewhere," said Dr. Michael Silverman, author of the study, Lawson scientist and chair of infectious diseases for Western's Schulich School of Medicine & Dentistry, LHSC and St. Joseph's.
"It's really causing a significant burden to the community. It's really affecting the hospitals in terms of these patients have required long periods of intravenous antibiotics and often surgery."
Still, slightly more than one in three of the patients with a history of injection drug use succumbed to the infection, according to the study.
"We thought it was very important that we study what's going on here and how we can treat them better and improve outcomes," said Silverman.
A medical dilemma
Doctors have debated the benefits of surgery for injection drug users.
"In patients who aren't injection drug users, there's a strong consensus that, yes, we should operate when they need it," said Silverman.
"The argument has been made that in injection drug users, maybe we shouldn't do it because quitting is very hard. Many will start injecting again and a heart that has a piece of metal in it is more easily infected than the natural valve. So now the chance of getting endocarditis again is even higher."
There's no desire on the part of cardiologists to put their patients in a worse position, said Silverman, so the challenge became finding a way to prevent them from becoming reinfected.
That's where in-hospital counselling was considered as an option.
"Historically, addiction counselling is something people would go to rehab for. It would be done as an outpatient or in a rehab facility," said Silverman. "We wondered whether it would be helpful to do it right then [while the patient is in hospital for endocarditis]."
The result found offering surgery increased survival rates by 56 per cent. But, that number ballooned to a 72 per cent reduction in deaths when in-hospital addictions counselling was offered.
The counselling was provided by a consultant who would meet with patients to provide education on risks for infection, harm reduction strategies and support toward addictions recovery, including referral to community supports.
Silverman said more studies are needed to fully explore these findings. But, fellow researchers suggest education and support for these patients is critical.
"The majority of the patients I see don't understand what they're doing to cause an infection and may be highly motivated to undertake a lifestyle change," said Dr. Sharon Koivu, author of the study, Lawson scientist, associate professor at Schulich Medicine & Dentistry and palliative-care physician at LHSC. "This study shows the importance of working with patients toward harm reduction and addiction recovery while they're still being treated in-hospital."
The study, "Clinical Characteristics and Factors Associated with Mortality in First-Episode Infective Endocarditis Among Persons Who Inject Drugs," is published in JAMA Network OPEN.