As the overdose and opioid crisis continues to cause harm to individuals, families, and communities across the Untied States, doctors and other medical professionals have begun reporting new negative consequences of the crisis that are relatively unexpected – but every bit as deadly as the primary negative consequences of the overdose crisis. The overdose crisis has claimed over a million lives since 1999. With the exception of a small decrease between 2018 and 2019, overdose deaths have increased every year since the beginning of the crisis 24 years ago. This article will focus on a related phenomenon, observed both nationwide and in the state of West Virginia: an increase in the prevalence of a heart condition called infective endocarditis caused by injecting drugs, known as IDU-IE.
In several peer-reviewed journal articles published in recent years, researchers have noted this increase with growing degrees of alarm. We’ll review the data from three of those articles and report that action steps clinicians and experts outline to help improve outcomes for people with IDU-IE. First, though, we’ll review the statistics on the overdose and opioid crisis nationwide and in West Virginia, then define the symptoms, causes, and treatments for endocarditis.
Overdose Crisis: National Data, 2019-2021
- 2019: 67,697 total drug overdose fatalities
- 50,178 involving opioids
- 2020: 78,056 total drug overdose fatalities
- 69,061 involving opioids
- 2021: 107,306 total drug overdose fatalities
- 73,453 involving opioids
Overdose Crisis: National Data, 2019-2021
- 2019: 870 overdose fatalities, or 52.8 per 100,000 people
- 665 involving opioids
- 2020: 1330 overdose fatalities, or 81.4 per 100,000 people
- 1,137 involving opioids
- 2021: 1,553 overdose fatalities, or 94.9 per 100,000 people
- 1,201 involving opioids
While those numbers for West Virginia do not appear to be high – with the disclaimer that even on overdose death is one too many – the rate per 100,000 people in 2019 was 250% higher than the national average of 21.6 per 100,000. In addition, the rate per 100,000 people in 2020 was 280% higher than the national average of 28.3 per 100,000. We don’t have final data on the national rate for 2021, but the current numbers for West Virginia indicate rates are still far higher than the national average.
Now let’s define and discuss IDU-IE, a.k.a. infective endocarditis caused by intravenous drug use.
What is Endocarditis?
The Mayo Clinic offers this definition:
“Endocarditis is a life-threatening inflammation of the inner lining of the heart’s chambers and valves. This lining is called the endocardium. Endocarditis is usually caused by an infection. Bacteria, fungi or other germs get into the bloodstream and attach to damaged areas in the heart.”
According to the Centers for Disease Control (CDC), endocarditis is “rare but often fatal.”
Symptoms of endocarditis may include:
Common symptoms of endocarditis include:
- Joint and muscle aches and pains
- Pain in chest when breathing
- Fatigue
- Fever, chills, or other flu-like symptoms
- Sweating, often at night
- Shortness of breath
- Inflammation in belly, legs, and/or feet
- Heart murmurs
- Sudden weight loss
- Blood in urine
- Pain in spleen area, under the left side of the rib cage
- Janeway lesions: painless red, brown, or purple spots on hands (palms) and feet (soles)
- Osler nodes: painful purple, red, or dark bumps on fingertips or tips of toes
- Petechiae: small brown, red, or purple spots on the skin, inside of the mouth, or in the whites of the eyes
Common causes of endocarditis include:
- Old age
- Complications with artificial heart valves
- Damaged heart valves
- Heart defects
- Complications with pacemakers
- Long term catheter use
- Poor dental health
- IV drug use
That’s the information on typical endocarditis. It’s important to note that injecting drugs can cause endocarditis. Now let’s shift our attention to IDU-IE.
What is the Relationship Between Injecting Drugs and Infective Endocarditis?
The study “Infective Endocarditis in Persons Who Use Drugs: Epidemiology, Current Management, and Emerging Treatments” indicates that infective endocarditis associated with intravenous drug use – IDU-IE – is caused by:
“…bacteria entering the bloodstream from the skin or injection equipment including syringes, needles, cookers, cottons, and water.”
We’ll now focus on increasing rates of endocarditis caused by injection drug use, specifically the increasing rates of IV heroin use in West Virginia. Before we move on, however, it’s important to understand the negative consequences of all types of endocarditis, as well as the most common treatments for all types of endocarditis.
Negative consequences include:
- Heart failure
- Damage to heart valves
- Stroke
- Abscesses in organs, including lungs, brain, heart, and others
- Pulmonary embolism
- Damaged kidneys
- Inflammation of spleen
Common treatments for endocarditis include medication with oral or injected antibiotics and surgery to repair or replace damaged heart valves. Short-term results for people with IDU-IE are generally good, with survival rates of 90 – 95 percent for in-hospital stays. Long-term outcomes for people with IDU-IE who receive surgery, however, are not good, with one report placing 5-year post surgery mortality at 62 percent and 10-year post surgery mortality at 57 percent.
Medical researchers theorize that one cause of the high mortality in IDU-IE patients is the fact that around 20 percent of patients with IDU-IE self-discharge from the hospital against medical advice (AMA). This may be the result of several factors, including:
- No SUD care during hospital stay
- No OUD-specific care during hospital stay
- Withdrawal during hospital stay
- Stigma from hospital staff
Whatever the reasons individuals with ID-IE have for discontinuing care, the outcomes for self-discharge against medical advice (AMA) are serious, and may include premature mortality, which is the medical way of saying early death.
Now let’s look at that study from West Virginia, and learn more about this growing public health problem.
Injection Drug Related Endocarditis in West Virginia
The study “Steep Rise in Drug Use-Associated Infective Endocarditis in West Virginia: Characteristics And Healthcare Utilization” examined cases of infective endocarditis in West Virginia in four university hospitals between 2014 and 2018. Here’s how the study authors describe their motive and methods for research effort:
“Life-threatening infections such as infective endocarditis (IE) are increasing simultaneously with the injection drug use epidemic in West Virginia (WV). We utilized a newly developed, statewide database to describe epidemiologic characteristics and healthcare utilization among patients with (DU-IE) and without (non-DU-IE) drug use-associated IE in WV over five years.”
Researchers analyzed data from 780 patients diagnosed with endocarditis in the five-year period. Here’s what they found (percentages represent the share of the total sample over five years, rather than the share for the indicated year):
2014:
- Total IE infections: 50
- Total patients who reported no drug use: 23 (11%)
- Total patients who reported drug use: 27 (5%)
2015:
- Total IE infections: 79
- Total patients who reported no drug use: 27 (12%)
- Total patients who reported drug use: 51 (9%)
2016:
- Total IE infections: 142
- Total patients who reported no drug use: 45 (21%)
- Total patients who reported drug use: 94 (17%)
2017:
- Total IE infections: 231
- Total patients who reported no drug use: 56 (26%)
- Total patients who reported drug use: 170 (30%)
2018:
- Total IE infections: 278
- Total patients who reported no drug use: 63 (29%)
- Total patients who reported drug use: 211 (38%)
2014-2018:
- Total IE infections: 780
- Total patients who reported no drug use: 214 (27%)
- Total patients who reported drug use: 553 (71%)
Now let’s look at the type of drugs used and the methods patients used to ingest them:
Type of Drug:
- Opioids: 86%
- Amphetamine: 33%
- Cannabinoids: 32%
- Buprenorphine: 25%
- Cocaine: 25%
- Benzodiazepines: 17%
- Methadone: 6%
- MDMA: 3%
- Other: 3%
Method of Use:
- Injection: 97%
- Inhalation: 37%
- Oral ingestion: 18%
Those percentages exceed 100 percent because among patients who reported drug use, over 60 percent reported using two or more drugs, and we can infer from that data that individuals who engaged in this type of polysubstance use – i.e. using more than one substance at a time – also engaged in more than one method of use.
Let’s discuss this data now.
Drug-Related Infective Endocarditis: What This Data Tells Us
The first thing we’ll note is the five-year increase in drug-related endocarditis. Between 2014 and 2018, the number of patients with DU-IE increased from 27 in 2014 to 211 in 2018.
That’s an increase of 680 percent.
The second thing we’ll point out is that among patients with DU-IE who reported drug use, 97 percent report intravenous drug use. If we apply this percentage to the totals, here’s what we get: 14 in 2014 and 189 in 2018, which works out to an increase of 687 percent among IV drug users. And among those, 86 percent reported opioid use. Therefore, what we see in this data is an increase in IE driven primarily by the injections of opioids.
That’s an outcome no one predicted.
This data tells us that the opioid crisis has far reaching public health implications, beyond those originally considered by policy makers and medical experts.
This data does not exits in a vacuum, either. In a news release published by the CDC, Dr. Nora Volkow describes a study in which she and a team of scientists from Case Western Reserve University in Cleveland, Ohio examined records from over a million patients from 77 hospitals during ten-year period from 2011 to 2022.
Here’s what they found:
2011:
- 4 cases if IE per day per million people with opioid use disorder (OUD)
- 5 cases of IE per day per million people with cocaine use disorder
2022:
- 30 cases if IE per day per million people with opioid use disorder (OUD)
- 23 cases of IE per day per million people with cocaine use disorder
Among patients with OUD, that’s an increase of 650 percent. Among patients with cocaine use disorder, that’s an increase of 360 percent. In addition, this study examined the effect of COVID-19 on a diagnosis of IE in patients with opioid use disorder or cocaine use disorder.
Here’s what they found:
- Diagnosis of COVID-19 doubled the risk of IE in patient with OUD or cocaine use disorder
- Risk of hospitalization for patients with IE:
- 68% in patient with COVID-19
- 59% in patients without COVID-19
Before we return to our discussion of rates of IDU-IE in West Virginia, we’ll offer analysis from Dr. Rong Xu, a scientist who participated in Dr. Vokow’s national-scale research effort:
“As the scientific understanding of long COVID develops, we can now include endocarditis as one long-term effect on key organ systems for people who inject drugs. Our study is one of the first to show this. It’s critical that we continue to monitor long term, broad impacts of COVID-19 on people who use drugs.”
It’s important to understand these developments in their broad context. This nationwide study helps us understand the interaction between COVID-19, IV drug use, and IE, because that’s our current situation: we’re on the heels of a worldwide pandemic that occurred in the midst of a national epidemic, and every piece of information we have can help us maintain the health and wellbeing of everyone in the country.
Now let’s look at how we can help people with OUD and IDU-IE.
Action Steps for Providers: What Can We Do to Prevent IDU-IE Mortality?
Medical experts experienced in caring for people IDU-IE outline a specific series of actions steps medical personnel, hospital staff, and treatment providers can take to improve outcomes for people with IDU-IE. These steps are appropriate for most clinical situations, but are designed for implementation in hospitals.
How Hospital Clinicians Can Help
- Clinicians can make medications for opioid use disorder (MOUD) available during the hospitalization or peri-hospitalization period for patients diagnosed with IDU-IE and OUD.
- Clinicians can offer outpatient antibiotic treatment for IDU-IE, including oral antibiotics and other targeted pharmacotherapies
- Patients with IDU-IE should receive education about substance use disorders, treatment for substance use disorders, and behavior that increases risk of further infection
- Patients with IDU-IE should receive education on the basic concepts of harm reduction, including needle safety, needle exchange programs, overdose education, and naloxone training
In addition, there are steps all healthcare providers can take for people who present with IDU-IE.
Tips for All Clinicians
- Enhance screening for SUD
- Enhance screening for infectious diseases
- Target immunizations for:
- Hepatitis (A, B, and C),
- Tetanus
- Pneumococcus
These measures are important because the contours of the overdose crisis are shifting as we write this article. Across the country, trends in drug use reveal a shift from opioids to polysubstance use, with methamphetamine and cocaine dominating this new development. This is particularly dangerous for two reasons:
- There is no gold-standard treatment for stimulant used disorder – i.e. methamphetamine and cocaine – as compared to OUD, for which medication-assisted treatment (MAT) with medications for opioid use disorder (MOUD) is both safe and effective
- The presence of illicit fentanyl in cocaine and methamphetamine substantially increases risk of accidental, fatal overdose
These studies help us understand the scope of problems we face as a nation, with regards to the opioid crisis. They tell us that in addition to the negative consequences of addiction, such as overdose, social problems, and emotional problems, the risk of infective endocarditis – which can lead to death – increases with intravenous drug use. That’s something all clinicians, treatment providers, and policymakers need to know, understand, and address by following the action steps we list above.