Episode 46
46: Reachable Moments
Drs. Nathan Nolan and Raagini Jawa discuss a case that traverses some of the intersections of ID and addiction medicine.
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Transcript
Hi everyone.
Sara Dong:Welcome to Febrile, a cultured podcast about all things infectious disease.
Sara Dong:We use consult questions to dive into ID clinical reasoning, diagnostics, and anti-microbial management.
Sara Dong:I'm Sara Dong, your host and a Med-Peds ID fellow.
Sara Dong:Here on Febrile, we use patient cases and chat with ID discussants to learn more about high-yield ID topics.
Sara Dong:I will first welcome our co-host today.
Sara Dong:Dr.
Sara Dong:Nathan Nolan.
Sara Dong:Nathan is a recent ID fellowship grad from the Washington University School of Medicine in St.
Sara Dong:Louis and currently is an instructor and a med ed fellow.
Sara Dong:He has a special focus on marginalized populations, including patients who use drugs and patients who are unhoused.
Sara Dong:Our guests discussant today is Dr.
Sara Dong:Raagini Jawa.
Sara Dong:Dr.
Sara Dong:Jawa is a clinical instructor at Boston University School of Medicine, where she practices Infectious Disease and Addiction Medicine.
Sara Dong:Her research has focused on the intersection of ID and addiction with a focus on harm reduction practices as a mechanism to reduce the rate of infectious complications occurring in people who inject drugs.
Sara Dong:Welcome to the show, friends.
Raagini Jawa:Thank you.
Nathan Nolan:Hi.
Sara Dong:Um, so before Nathan takes us to the case, we like to ask as everyone's favorite cultured podcast, if you could share a little piece of culture or something that brings you happiness.
Raagini Jawa:Nathan, would you like to go first?
Nathan Nolan:Sure.
Nathan Nolan:I don't know if this fits the normal definition that you have, but, uh, I recently was on vacation in Puerto Rico.
Nathan Nolan:And I got the opportunity to go to a bioluminescent bay, which is where they have the little plankton that light up.
Nathan Nolan:And it was one of the coolest experiences and it was just so beautiful.
Nathan Nolan:And.
Nathan Nolan:I would say, if you ever get an opportunity to go to Puerto Rico and do that, uh, you definitely should.
Raagini Jawa:That sounds a very exciting, I am really jealous and I need to make a trip to Puerto Rico.
Raagini Jawa:I'm a photography junkie and I'm, I'm like waiting for something beautiful to just show up that I can photograph.
Raagini Jawa:New England winters are very dreary.
Raagini Jawa:Um, what brings me joy?
Raagini Jawa:I mean, right now, what brings me joy is TLC's 90 Day Fiancé.
Raagini Jawa:I will tell you, I am such a reality show junkie.
Raagini Jawa:There is nothing more relaxing than coming home from a long day of ID consults or HIV clinic or whatever.
Raagini Jawa:And then just being like, I'm going to watch 90 Day Fiancé re-runs.
Raagini Jawa:Um, it's fantastic.
Raagini Jawa:If you haven't enjoyed an episode.
Raagini Jawa:I highly encourage you do that.
Raagini Jawa:This is not sponsored by TLC but I, I, it's a really great show.
Raagini Jawa:It's sometimes mind numbing, but, um, that's my guilty pleasure.
Sara Dong:Sometimes that's what you need though.
Sara Dong:A little bit of mind numbing at the end of the day, or at least I do.
Sara Dong:Awesome.
Sara Dong:Well, those are both great.
Sara Dong:Um, so today's consult question is about a 35 year old male who is admitted with fevers.
Sara Dong:So I will throw it over to Nathan.
Nathan Nolan:Okay.
Nathan Nolan:So we have a 35 year old male patient who has a history of substance use disorder.
Nathan Nolan:And specifically he uses injection opioids.
Nathan Nolan:And he's admitted for fevers that have been ongoing for two weeks.
Nathan Nolan:He has a history of hepatitis C that has been untreated.
Nathan Nolan:He uses fentanyl by way of injection and uses daily.
Nathan Nolan:He tries to use new needles when able, but sometimes has to re-use his needles if he's not able to get new ones.
Nathan Nolan:He does not routinely clean his skin before injection.
Nathan Nolan:He lives within the city, but is unstably housed.
Nathan Nolan:He describes his situation as couch surfing.
Nathan Nolan:He has history of skin infections in the past, but has never had to be admitted to the hospital for any serious, uh, injection site related injury or infection for the last two weeks.
Nathan Nolan:He has been noting night sweats and fevers.
Nathan Nolan:He also reports low energy, low appetite, and progressive difficulty with his breathing today.
Nathan Nolan:He had some more trouble with his breathing and decided to present to the emergency room.
Nathan Nolan:He has no prior medical history, no history of any major surgery.
Nathan Nolan:On the initial evaluation in the ER, he looks moderately ill and he's found to have a fever of 38.1 degrees Celsius.
Nathan Nolan:His heart rate is 111 and his respiratory rate is 20.
Nathan Nolan:He was breathing comfortably on room air and his blood pressure was stable.
Nathan Nolan:His heart exam was significant for a systolic murmur heard best at the right sternal border.
Nathan Nolan:He has lower extremity edema, which is 2+.
Nathan Nolan:He has some faint crackles in the left lung.
Nathan Nolan:And then his initial lab work comes back as a CBC with a white count of 18000 with 82% neutrophils with 3% bands.
Nathan Nolan:His hemoglobin is 13.
Nathan Nolan:His platelets are 180,000 and a metabolic panel demonstrates a sodium of 1 35, potassium of 4, chloride 101, bicarb 24, BUN 37, Cr 2 with an unknown baseline.
Nathan Nolan:His glucose is 98.
Nathan Nolan:AST is 93, ALT 92.
Nathan Nolan:On chest x-ray, he has a peripheral opacity in the left lower lung field concerning for an infectious process.
Nathan Nolan:So blood cultures are obtained and he's admitted to the hospital.
Nathan Nolan:And so you're asked to see him as a consult.
Nathan Nolan:Do you have any initial thoughts about this case or how you might approach a patient that you're seeing that may have injection related infection?
Raagini Jawa:Yeah.
Raagini Jawa:Thanks for this case, Nathan, this clearly is a patient who is quite unwell.
Raagini Jawa:Um, he's young, he's coming in with symptoms for two weeks with SIRS and perhaps a pulmonary process.
Raagini Jawa:And I think that the point of this podcast is really to not only sort of dispel myths about people with substance use disorders, but, but I think our differential as ID docs and medical docs is pretty much the same as any other patient.
Raagini Jawa:This patient has some sort of infection.
Raagini Jawa:And, um, I don't, I think that when I approached this sort of patient initially, um, my differential diagnosis, it's the same as a patient without addiction.
Raagini Jawa:It's a homeless patient with two week long febrile illness, SIRS, leukocytosis with bandemia, AKI, transaminitis, and then all of these physical exam findings that are really concerning for some sort of pulmonary cardiac process.
Raagini Jawa:So new systolic murmur, new lower extremity edema, some sort of left lower lobe infiltrate.
Raagini Jawa:So.
Raagini Jawa:I'm thinking, oh gosh, patient probably has a bacterial process.
Raagini Jawa:Pneumonia, maybe a cardiac process.
Raagini Jawa:Because of their homelessness, as an ID doc, I'd always be worried about something a little bit more insidious like TB.
Raagini Jawa:Um, and so those would be the things highest on my differential that I hope like most of our medical colleagues would be keeping, um, highest on their differential.
Raagini Jawa:But your question Nathan was really about, well, how do you sort of approach the fact that this patient is, is unlike others and has an additional past medical history of, uh, injection drug use specifically opioid use.
Raagini Jawa:And I do think that that adds a new flare to our differential diagnosis.
Raagini Jawa:And that really means that our differential diagnosis should have the typical, you know, pneumonia, cardiac process, TB, but we should have a higher index of suspicion for um, hematogenous introduced bacterial infections or fungal processes.
Raagini Jawa:So this could be like endocarditis, osteomyelitis, septic arthritis, a serious skin and soft tissue infection that may be the patients not necessarily telling you about that could be concurrent with the thing that is causing him to have shortness of breath.
Raagini Jawa:Um, and then the other things on the differential that probably don't fit with this illness script could be like an acute viral illness.
Raagini Jawa:Um, so.
Raagini Jawa:Differential is pretty much the same, but when you add injection drug use into the past medical history, it does make the index of suspicion higher for other hematogenously introduced bacterial and fungal processes.
Nathan Nolan:Wow.
Nathan Nolan:That was a really excellent discussion.
Nathan Nolan:Thank you for that.
Nathan Nolan:I can give you a little bit more of the case if you're ready.
Raagini Jawa:Sure.
Nathan Nolan:So the patient was admitted to the internal medicine service and he was empirically started on ceftriaxone and vancomycin.
Nathan Nolan:Uh, shortly after admission, he becomes diaphoretic with severe abdominal cramps, nausea and diarrhea.
Nathan Nolan:His blood pressure increases to 167/101 and his heart rate is now 120.
Nathan Nolan:He appears agitated.
Nathan Nolan:So I guess my question at this point is you talked about how there may be some other levels or other components of this presentation.
Nathan Nolan:And I would say that my concern is, as a physician would be that this patient might have a secondary process on top of whatever their infection is that's ongoing and you know, this could be related to his opioid use disorder.
Nathan Nolan:How do you go about, uh, addressing opioid withdrawal in patients like this who may be admitted with a unrelated processes?
Raagini Jawa:So I think as any medical or specifically for infectious disease providers, it's important for us to think in our differential diagnosis, not just like the typical complications of drug use, but also the mimics of sepsis and sepsis like phenomena.
Raagini Jawa:So opiate withdrawal and, and many drug withdrawal syndromes oftentimes can be mimicking sepsis and autonomic dysregulation.
Raagini Jawa:And so for any patient with substance use disorder, I always like to ask, not only signs and symptoms that they're presenting with, but also when is the last time they used, um, What that means is what are they using?
Raagini Jawa:And are they on any medications for their drug use?
Raagini Jawa:Um, that could impact their risk of experiencing opiate withdrawal.
Raagini Jawa:Uh, if it's not acutely managed in the hospital setting.
Raagini Jawa:And yes, we go to medical school and get our bachelor's and get masters and, you know, get all these special degrees.
Raagini Jawa:But for patients with addiction, when they're using drugs, they are the experts of their own bodies and they understand the keen pharmacokinetics and dynamics of the specific types of drugs that they're using.
Raagini Jawa:So the questions that I like to ask my patients is.
Raagini Jawa:Do you have any symptoms of withdrawal at this moment, from whatever substance that they're using, whether it be opiates, whether it be stimulants, whether it be alcohol, benzodiazepines.
Raagini Jawa:The symptoms of opiate withdrawal are sort of at the same timeline that you told me about Nathan.
Raagini Jawa:They start anywhere from 24 to 36 hours since the last time they use.
Raagini Jawa:And again, that can vary depending on the potency and the type of opioid that patients are using.
Raagini Jawa:So if their body is dependent on sort of longer acting opioid agonists, um, their withdrawal symptoms may not come for a little bit of time, but if they're using things like fentanyl which is very much, um, infiltrated into the drug supply, at least it has in New England, patients start experiencing withdrawal symptoms very quickly, sometimes even before the 24 hour period.
Raagini Jawa:So they might start feeling sick in the emergency room bay and these symptoms can be very similar to sepsis, right?
Raagini Jawa:They can be diaphoresis, dilated pupils, rhinorrhea, diarrhea, abdominal cramping, nausea, muscle spasms, anxiety, piloerection.
Raagini Jawa:In the hospital, at least in my hospital, we have these inbuilt like COWS (Clinical Opiate Withdrawal Scale) scores, uh, which is an opiate withdrawal scale that our nursing colleagues can sort of score up patients.
Raagini Jawa:But depending on the type of hospital or clinic system you might be in, you can always Google it and find out like, what are the typical signs and symptoms for opiate withdrawal?
Raagini Jawa:And you can score your patient yourself, and then say, gosh, if they're scoring like an eight or a 10 on the COWS scale, then that probably means that they're experiencing withdrawal symptoms and that might be confounding or contributing to the worsened hemodynamics that the patient is currently going through.
Raagini Jawa:So that's how I address the whole "is my patient going through opiate withdrawal at this moment?"
Raagini Jawa:Now I will make this note.
Raagini Jawa:Okay.
Raagini Jawa:The first question should not just be, are you going through opiate withdrawals and what's your COWS scale?
Raagini Jawa:The next question needs to be, well, what the heck am I going to do about it?
Raagini Jawa:And you have so many tools to actually manage patients with opiate withdrawal, but, but your patient needs to be engaged and you need to have a conversation with your patient on how they think would be best to manage their withdrawal symptoms.
Raagini Jawa:To help them feel comfortable and it sort of take the opiate withdrawal symptoms off of their plate when they're already feeling sick from a bacterial or fungal process.
Raagini Jawa:And I think we, as clinical providers could do better in this realm.
Raagini Jawa:I think sometimes we, we know like, oh, I'm going to ask.
Raagini Jawa:Are they having withdrawals?
Raagini Jawa:I know how to do the score.
Raagini Jawa:And then we sort of feel like, oh gosh, I don't know what to do next.
Raagini Jawa:Am I enabling the patient?
Raagini Jawa:Am I making their drug use worse?
Raagini Jawa:Am I going to make their hemodynamics worse?
Raagini Jawa:And the answer is no.
Raagini Jawa:Drugs have very typical pharmaco kinetics and dynamics patients withdraw.
Raagini Jawa:And us as medical providers have a responsibility to manage the withdrawal in whatever setting in the outpatient setting or in the hospital.
Raagini Jawa:What I would advise in this stage is once you've identified patient is withdrawing, is to work with the patient, ask them what their goals are for management of the opiate withdrawal symptoms short and long-term and use that hospital stay as a reachable moment.
Raagini Jawa:Um, and there's a lot of literature on what reachable moments are.
Raagini Jawa:But it's really your opportunity to reach out to the patient and say, Hey, I'm here to treat your infection.
Raagini Jawa:I'm here to make you feel better.
Raagini Jawa:And I also don't want you to withdraw and this sort of fosters a very respectful, trusting relationship and the go-to medications that you have in your armamentarium as a clinical provider are not only like the stigmatized medications, like methadone and buprenorphine that sometimes clinicians feel uncomfortable prescribing, but it's stuff that we like give all the time, like NSAIDs, like Tylenol, like hydroxizine, clonidine, Bentyl.
Raagini Jawa:We can prescribe all of these medications to help our patients feel more comfortable.
Raagini Jawa:You can also prescribe your patients short or long acting opioids and other medications for opiate use disorder, whether they be methadone and buprenorphine, both that are opioid agonists or partial opiate agonist.
Sara Dong:I just want to make sure we take a quick pause here for you to tell us just a little bit about how to gather a history around IV drug use, because I think there are a lot of listeners who maybe aren't as familiar with what to ask.
Sara Dong:And so specifically, what might be the types of questions you ask and how those are useful to you as you think about your patient.
Raagini Jawa:Oh, of course.
Raagini Jawa:So ID docs love histories, and I love this.
Raagini Jawa:If I'm taking care of a patient with injection drug use, it is my responsibility to not only get a good social history, but, uh, specifically an injection drug use history.
Raagini Jawa:And so I like to ask nitty gritties, what drugs are my patients injecting or using?
Raagini Jawa:Cause it doesn't necessarily mean that my patients are going to be using an injection route of drugs.
Raagini Jawa:Right?
Raagini Jawa:They might be inhaling.
Raagini Jawa:They might be smoking.
Raagini Jawa:They might be taking oral medications or other routes of administration.
Raagini Jawa:And I like to ask what drugs they're using.
Raagini Jawa:So is it opioids only or is it opioids and stimulants?
Raagini Jawa:And if it's stimulants then which stimulants, like, is it cocaine, crack, methamphetamine?
Raagini Jawa:And the reason why is because not only will that guide you on their withdrawal syndrome, that will also potentially guide you on some of the risk taking behaviors they're engaging in and it will probably guide you on some of the injection drug use related complications they might be facing.
Raagini Jawa:So for instance, things like methamphetamine, so stimulants are vasoconstricting.
Raagini Jawa:And so those patients often tend to have a lot of ischemic, uh, skin infections.
Raagini Jawa:Um, or if patients are engaging in methamphetamine with other substances there that's been associated with, uh, riskier injection drug use and sexual risk behaviors.
Raagini Jawa:So the questions keep going.
Raagini Jawa:Um, the questions you can ask are when was the last time they used, how are the patients injecting?
Raagini Jawa:Um, and how frequently are your patients injecting?
Raagini Jawa:And you might be surprised.
Raagini Jawa:Some patients will say I live at home.
Raagini Jawa:I inject in the bathroom maybe once a day.
Raagini Jawa:Um, and that might not be the same type of patient who might be unstably housed, who might say I have no place to inject.
Raagini Jawa:I'm injecting 10, 15 times a day.
Raagini Jawa:Um, and then the obvious next questions would be.
Raagini Jawa:Where are you getting your injection drug preparation equipment from, is it the local needle exchange?
Raagini Jawa:Is it the local pharmacy?
Raagini Jawa:Are you reusing your injection drug preparation equipment or are you stealing it or are you taking it from one of your family members again?
Raagini Jawa:Again, as an ID doc, all of those risk behaviors have implications for the type of infectious complications this patient might be having that I need to address, maybe not in that moment, but maybe down the stream in the hospital stay.
Raagini Jawa:The other questions I ask it'll be, you know, how are you cooking your drugs?
Raagini Jawa:That means are you using a flame to dissolve your drugs?
Raagini Jawa:And where are you getting your solvents from?
Raagini Jawa:Is it tap water?
Raagini Jawa:Is it.
Raagini Jawa:Uh, toilet water.
Raagini Jawa:Is it spit?
Raagini Jawa:Is it snow?
Raagini Jawa:Um, balls?
Raagini Jawa:And you'd be really surprised because all of those sources of, uh, solvents that our patients could be using may have different bacterial and fungal contaminants within them that could cause downstream complications.
Raagini Jawa:And so the last few questions I like to ask is number of times they've reused or shared their injection equipment.
Raagini Jawa:Um, if they have engaged in.
Raagini Jawa:Uh, cotton shots.
Raagini Jawa:And for those of you who are less familiar with cotton shots, cottons are typically filters that are used to take out any sort of.
Raagini Jawa:Uh, contaminants and drug products, as you're sucking up the drug from your cooker, which is the receptacle on which your patient is probably cooking drugs and often cotton shots are the drug that's residually left behind that patients may or may not save or sell in order to, you know, uh, have it for a rainy day that when you're not able to, um, resource your drugs reliably, you still have something to prevent you from getting sick.
Raagini Jawa:Um, because you know that that cotton is probably loaded with a little bit of drug products in it.
Raagini Jawa:In my mind, if a patient is engaging in cotton shots, that's like a real red flag that this patient is really struggling.
Raagini Jawa:We need to engage them.
Raagini Jawa:They're high risk of bacterial and fungal complications.
Raagini Jawa:Um, on the other stuff is like, uh, you know, we ask about past medical history.
Raagini Jawa:So injection past medical history is going to be, are they having prior skin and soft tissue infections?
Raagini Jawa:Have they had serious infection, infectious complications, like abscesses or endocarditis or osteomyelitis?
Raagini Jawa:Have they had a prior immunocompromised infection like HIV?
Raagini Jawa:Have they ever been on PrEP?
Raagini Jawa:And then how are they supporting their habit?
Raagini Jawa:Our patient is unstable housed.
Raagini Jawa:It seems like this person's really struggling, maintaining their, you know, usual, uh, ability to do their day to day.
Raagini Jawa:Um, how are they may, you know, supporting their habit?
Raagini Jawa:Is it through, um, selling drugs or peddling or is it through transactional sex or other risky behaviors?
Raagini Jawa:All of these questions should be in our background for talking to patients with injection drug use, um, and addiction.
Raagini Jawa:And, and trust me while this hasn't been studied formally, I do think that if a clinician can have an open, honest conversation with a patient who's struggling with injection drug use and ask them all of these history, uh, uh, questions.
Raagini Jawa:Your patient will very naturally open up.
Raagini Jawa:You might not even have to prompt these questions.
Raagini Jawa:They will just tell you because it might be one of the first times that that patient is heard an empathetic provider actually ask them what they're doing and how they're feeling.
Raagini Jawa:Um, uh, it stinks guys, like there's so much stigma around patients with addiction.
Raagini Jawa:And while I'd love to think that the medical environment is immune to that stigma.
Raagini Jawa:I think we're getting there, but it's taking some time and it's going to need some champions like you all to sort of break those barriers, um, and, and help this patient population feel more.
Raagini Jawa:That the hospital is a welcoming environment.
Sara Dong:Yeah.
Sara Dong:Thanks so much.
Sara Dong:I really wanted to make sure we outlined those questions explicitly.
Sara Dong:And I totally agree with you.
Sara Dong:I think it makes a huge difference when you have these conversations with our patients, uh, to try to develop that trust.
Sara Dong:But also I think to make sure we're continuing to model that to others around you in the healthcare setting.
Raagini Jawa:So I do a lot of harm reduction research among learners, and, uh, if you teach trainees on having safe injection practice discussions with patients, it actually has shown to be associated with increased compassion satisfaction towards caring for this patient population.
Raagini Jawa:And that has implications, right?
Raagini Jawa:Like if we feel compassionate to someone suffering, we also provide them better care.
Raagini Jawa:And I think that oftentimes, like these questions are not taught in medical school.
Raagini Jawa:And so we can only model it through these podcasts and model it through champions, local champions who are taking care of these patients.
Raagini Jawa:Uh, but I really do hope that there is a culture change over the years.
Raagini Jawa:Well, our patients are coming in more and more with infectious complications.
Raagini Jawa:They're more and more in your hospital words as you're being seen by hospitalists, by seeing by internal medicine, med peds trainees, family medicine, surgical trainees, um, and, and this dialogue needs to be part of our conversation guide.
Nathan Nolan:So that was a really great explanation.
Nathan Nolan:And, uh, I appreciate you talking about also the use of, of short acting opioids in, uh, treating withdrawal.
Nathan Nolan:You know, oftentimes we have patients that come in that, uh, like you said, trying to meet a patient where they're at.
Nathan Nolan:They may not be ready to be on some sort of agonist therapy, or maybe they have a procedure that's going to happen and they may need, um, analgesia more than what might be provided with something like buprenorphine.
Nathan Nolan:So, uh, we'll move on with the case.
Nathan Nolan:Um, the patient has started on buprenorphine.
Nathan Nolan:This improves his symptoms of withdrawal.
Nathan Nolan:He is also provided with symptomatic relief, including loperamide and Clonidine.
Nathan Nolan:On hospital day two, his blood cultures turned positive for Gram positive cocci in chains.
Nathan Nolan:Uh, repeat blood cultures are obtained and the transthoracic echocardiogram is performed.
Nathan Nolan:This demonstrates a three centimeter vegetation on the tricuspid valve on hospital day three.
Nathan Nolan:The organism is identified as Streptococcus mitis.
Nathan Nolan:And so given this information, is there anything you would do different in regards to this patient's management?
Raagini Jawa:So Nathan, I'm going to probe you and say, what do you mean by the patient's management?
Raagini Jawa:Do you mean the antibiotic management, the medication for opiate use disorder management or harm reduction management?
Nathan Nolan:Potentially all of the above, but I think in this moment you have new microbiologic data, so probably would be the management of the actual infection itself.
Raagini Jawa:Totally.
Raagini Jawa:So for a Strep mitis species that is typically, uh, uh, very sensitive pathogen.
Raagini Jawa:I think that narrowing the antibiotics is probably most appropriate in this case.
Raagini Jawa:Typically Strep mitis is, is a if I don't remember if you said it's penicillin susceptible.
Raagini Jawa:So I would, I would narrow it down to the most susceptible type of agent, um, to simplify the patient's antibiotic regimen.
Raagini Jawa:In terms of the medications for opioid use disorder management seems like the patient was started on buprenorphine for, or opioid withdrawal.
Raagini Jawa:And I think that this would be an appropriate time to check in on the patient and see how are those symptoms going?
Raagini Jawa:Is the patient's withdrawal being managed appropriately on the current dose and or does that dose need to be titrated further?
Raagini Jawa:Typically buprenorphine is dosed either once or twice or thrice a day.
Raagini Jawa:Um, and the questions to ask your patient for any medication for opioid use disorder, there's actually three goals.
Raagini Jawa:Um, this goes for methadone and for buprenorphine, the first goal, uh, of titrating a medication, um, like an MOUD is managing the opiod withdrawal syndrome symptoms.
Raagini Jawa:The second goal is to prevent cravings.
Raagini Jawa:And the third goal is if you were to use drugs on top, that there'll be like a blocking dose that you wouldn't actually be able to have, uh, an intoxication syndrome, um, if you were to use.
Raagini Jawa:And so that's really the goals that you should be trying to achieve even in the hospital, stay.
Raagini Jawa:For a patient who is newly started on a medication for opioid use disorder, so I think the management here would be checking in on the patient, seeing how they're doing on their withdrawal symptoms.
Raagini Jawa:If those are managed, you're a rock star, then see if there you're being able to do.
Raagini Jawa:You know, the goal number two or three, are there cravings managed?
Raagini Jawa:Because being in the hospital is no joke.
Raagini Jawa:It stinks.
Raagini Jawa:And especially for patients who are struggling with a substance use disorder and unstable housing, being in a closed hospital, there is nothing worse.
Raagini Jawa:It feels like jail.
Raagini Jawa:And so patients will often have cravings as they're feeling better.
Raagini Jawa:And.
Raagini Jawa:Right.
Raagini Jawa:Um, and they might want to go out and use and treat themselves.
Raagini Jawa:And so your role would be to check in to see if we need to do dose titration.
Raagini Jawa:And then as an ID doc, the pathogens that are isolated are the biggest hint for me, just to figure out what the risk behavior was for a patient who's using drugs.
Raagini Jawa:Um, one of my favorite patients had Serratia marcescens, uh, isolated and her blood cultures who had a history of injection drug use.
Raagini Jawa:And for those of you who are less familiar with this type of pathogen, it's a pink tinged bacteria that typically colonizes the outside of like your faucets, um, and your sinks.
Raagini Jawa:And so when I asked her, I was like, so how are you injecting?
Raagini Jawa:And she's like, Hey Doctor Jawa, you know, I, uh, inject tap water because I think that's the safest.
Raagini Jawa:And that's where this pathogen was introduced.
Raagini Jawa:And so similarly, this patient is coming in with Strep mitis, which is typically an oral flora.
Raagini Jawa:And so that is a hint to me to say, you know, you have bacteria in your blood, by the way, the bacteria that was found in your blood is actually a mouth bacteria.
Raagini Jawa:Talk to me again about how you're injecting and, and you might realize that the patient will say, Hey, you know what?
Raagini Jawa:I am licking my needles before I inject, because I want to make sure that the potency of the drug that I'm injecting is good.
Raagini Jawa:Or I lick the needle after I inject to make sure that I don't waste the drug, or I lick my skin after I'm bleeding from my injection site, so as to help with the coagulation of the blood or, I spit as my solvent when I'm mixing my drugs or I'm sharing my injection drug preparation equipment.
Raagini Jawa:So the pathogen is key in engaging your patient in a conversation.
Raagini Jawa:Once you've identified the pathogen, it like blows their world.
Raagini Jawa:I kid you not, like it really helps, um, patients identify like, oh, I have an infection.
Raagini Jawa:I think now I understand where it came from.
Raagini Jawa:And this also then leads to the next step of you partnering with the patient to identify realistic risk mitigation strategies.
Raagini Jawa:So let's say the patient says I'm licking my skin before or after I inject, maybe you can talk to them about, well, maybe we can think about other ways, like maybe using an alcohol swab or soap water or, um, if the patient is saying I'm having to resort to using spit to solubilize my drug saying like, Hey, let me help you find the local needle exchanges, or maybe I can prescribe you those ampules of saline or water at the time of discharge.
Raagini Jawa:Again, it's, it's giving, um, tools for your patient to keep them safe.
Raagini Jawa:In HIV, we do this all the time.
Raagini Jawa:Um, and, and frankly, in anything, we do this all the time.
Raagini Jawa:Like for our diabetic patients, we teach our patients how to inject insulin.
Raagini Jawa:We also give them glucose tablets along with the insulin to keep themselves safe.
Raagini Jawa:And so when you have a patient with injection drug use, you've isolated the pathogen, you are empowered to say, okay, let's come up with a strategy that works for you.
Raagini Jawa:And like, here are the tools.
Raagini Jawa:And that tool might be cleaning your skin.
Raagini Jawa:That tool might be finding the local needle exchange.
Raagini Jawa:That tool might be something else like cooking your works for like two minutes so that you can try to sterilize the bacteria that's in your cooker.
Raagini Jawa:So, yeah, the other thing is a Strep mitis in the mouth, and so from a physical exam perspective, you should always examine your patient's mouth.
Raagini Jawa:Oftentimes patients may have non-optimal dental hygiene and, and, and you can have odontogenic infections that can lead to hematogenous infections.
Raagini Jawa:And so, you know, they might have a broken tooth or whatever that could have led to the, this bacteria going into their bloodstream.
Raagini Jawa:So, yeah.
Raagini Jawa:I hope by my conversation about this, your role is more than just like, here's how I narrow the antibiotics based off of what microbiology told me.
Raagini Jawa:And I empower you to say, not only can I do that, but I can manage their MOUD, their medication for opiate use disorder.
Raagini Jawa:I can check on them for their cravings and I can partner them with how to reduce their risk, um, of injection drug use.
Nathan Nolan:Excellent.
Nathan Nolan:All right.
Nathan Nolan:So that was a really, uh, great and robust discussion on harm reduction and how we might further tailor our care for this patient.
Nathan Nolan:Thank you for that.
Nathan Nolan:Um, ultimately the patient is improving on antibiotics and he did have a consultation with cardiothoracic surgery, but they didn't feel like he needed any kind of surgical intervention.
Nathan Nolan:Susceptibility testing revealed that the Strep mitis was highly susceptible to penicillin.
Nathan Nolan:The PICC line was placed and he has started on ceftriaxone with a plan for a four week course of IV antibiotics.
Nathan Nolan:His medical teams, uh, deems that he is not a candidate for outpatient parental antibiotics.
Nathan Nolan:So, I guess in this moment, my question for you, Dr.
Nathan Nolan:Jawa is when you're seeing patients in the hospital for complications of their injection drug use, um, you essentially kind of have a captive audience or, or patients that are there for what you were referring to as a reachable moment.
Nathan Nolan:Um, what other screenings or interventions would you do while they're in the hospital?
Nathan Nolan:For example, would you screen them for STI or, uh, bloodborne viruses?
Nathan Nolan:And then I guess on top of that, um, you know, this is a patient that his team has said, you know, he, uh, is seemingly not safe to discharge with a PICC line or on outpatient, IV antibiotics.
Nathan Nolan:Um, What do you do in that circumstance?
Nathan Nolan:Do you preemptively make a plan for that patient in case they need to discharge a prematurely?
Raagini Jawa:Um, excellent questions.
Raagini Jawa:So yes, you have a captive audience.
Raagini Jawa:When does this ever happen?
Raagini Jawa:And so yes, to all of the above, you can do anything and everything.
Raagini Jawa:And this is also the opportunity for you to sort of change the dynamic of the experience that the patient has had traditionally in the health facility.
Raagini Jawa:Right?
Raagini Jawa:So these patients are often very stigmatized against the health systems.
Raagini Jawa:They don't even want to come to see you.
Raagini Jawa:They will come only when they are so sick that they probably can't function.
Raagini Jawa:And so you can provide the clinical intervention.
Raagini Jawa:Um, like STI screenings and, um, discussions about pre-exposure prophylaxis and initiation of pre-exposure and post-exposure prophylaxis, depending on if your patient is engaging in injection drugs.
Raagini Jawa:Uh, engaging and sharing of injection drug use preparation equipment, um, or engaging in transactional sex, which many of your patients may disclose to you that they are.
Raagini Jawa:And again, pre-exposure prophylaxis is a, uh, an indication for PrEP.
Raagini Jawa:So you can do all of those things.
Raagini Jawa:So what I like to do is I screened for the hepatitides.
Raagini Jawa:I screened for STIs.
Raagini Jawa:I vaccinate my patients for the Hep B hepatitis B, if they need boosters, also have, uh, vaccinate them for COVID.
Raagini Jawa:If they haven't already received that, discuss with them about pre-exposure and post-exposure prophylaxis.
Raagini Jawa:For our female patients who are injecting drugs, oftentimes who are of childbearing age, you can also discuss with them contraception and initiate them on contraception, whether it be some sort of, uh, uh, you know, implanon or whatever.
Raagini Jawa:Um, and all of those interventions you can do in the hospital, uh, The other critical thing you can do while your patient is in the hospital is see what are their outpatient linkages?
Raagini Jawa:So do they have a primary care doctor?
Raagini Jawa:Do they have any social worker who can help them with like, uh, paperwork or housing?
Raagini Jawa:Because oftentimes this patient is probably unlinked to medical care, and this is your opportunity to sort of wrap your arms around them and say, how can I help you?
Raagini Jawa:Um, In terms of the ID questions is can we come up with a preemptive plan?
Raagini Jawa:Well, I challenge us to say, can we come up with a preemptive ID and an addiction plan?
Raagini Jawa:So for a patient on buprenorphine, um, who might be, uh, you know, not necessarily linked to an outpatient buprenorphine clinic, then the preemptive plan to leave to, you know, your night float residents is if this patient was to leave as a patient directed discharge for whatever reason, then from an addiction standpoint, they should be getting a bridge script of buprenorphine.
Raagini Jawa:So several days of buprenorphine, a prescription so that they don't go into withdrawal, they need an appointment the next day, um, to some sort of bridge clinic or primary care provider or urgent care that can continue prescribing them this medication.
Raagini Jawa:And then in terms of the ID plan, well, this patient has a really sensitive pathogen Strep mitis, which is penicillin susceptible.
Raagini Jawa:There are probably many other agents that you can give orally, um, that will have as good, uh, sort of penetration into tissue that you could give, um, for the duration of their four week course that you know, the data for partial oral antibiotics, we can sort of discuss later.
Raagini Jawa:Um, but, but I think that, um, when you have a captive audience, you have a reachable moment to change the dialogue on how we provide care for this patient population to engage them into primary care and addiction care as an outpatient.
Raagini Jawa:And have contingencies on, if there was to be a patient direct discharge contact the ID fellow, and then they can provide you whatever the, the institutional, uh, oral equivalent antibiotic would be for this patient.
Nathan Nolan:Alright, so our patients now, uh, about two weeks into treatment, um, he's doing well on his, uh, dosing of buprenorphine.
Nathan Nolan:He's not having any withdrawal symptoms.
Nathan Nolan:He feels pretty well.
Nathan Nolan:In fact, he's, uh, getting a little bit stir crazy, doing laps around the hospital ward.
Nathan Nolan:And he's asking you if he can leave the hospital and not have to stay there for another two weeks to finish out his week course.
Nathan Nolan:And you know, this is something I think, as ID physicians, we're faced with a lot where we're trying to make, uh, decisions, um, both what's best for our patient, but then taking our patient's values and their thoughts into consideration.
Nathan Nolan:I was wondering in, in this type of situation, how do you have that conversation with patients about whether or not they're eligible for IV antibiotics in the outpatient setting or whether or not they might be good candidates for partial oral antibiotic treatment?
Nathan Nolan:If they don't feel that they can stay in the home.
Raagini Jawa:So, this is such an important question and there is so much variability on eligibility of out outpatient parenteral antibiotic treatment via a PICC line.
Raagini Jawa:Um, particularly among patients who inject drugs and I've written about this with some of my colleagues in, um, as a commentary, just sort of looking at data on what are the previously cited barriers to home-based OPAT for people who use drugs and the typical barriers for home-based OPAT it could be anything like unstable housing, lack of transportation, not living with a responsible adult who can support infusions this whole, uh, idea that patients who use drugs are at risk for misusing their PICC line, um, and, uh, you know, having, uh, an access to the PICC line and this risk of litigation.
Raagini Jawa:If the patient misuses the PICC line and gets a PICC line associated infection or some other adverse, uh, clinical symptom.
Raagini Jawa:Um, and then this, the other side of barriers are this need for mental health and substance use disorder treatment, lack of data on outcomes for OPAT, with people who inject drugs and inadequate Medicare coverage for non home bound patients and this lack of existing care models.
Raagini Jawa:So you can imagine that in the United States, why isn't it standard of care for patients who use drugs, to be discharged, um, on OPAT after the two week mark, which is typically what we do for every other patient who is not doesn't have like the stamp of patient who uses drugs.
Raagini Jawa:Um, it's because of a lot of systemic, um, variability and some stigma and some lack of infrastructural support that exists for patients.
Raagini Jawa:So while some institutions have figured out avenues to support patients who use drugs with PICC lines in their homes, others have not.
Raagini Jawa:So am I surprised that the initial team deemed this patient not eligible?
Raagini Jawa:No but do I, would I challenge them?
Raagini Jawa:Absolutely.
Raagini Jawa:Uh, because I think as with any other medical syndrome, that is someone is, uh, admitted for, um, Antibiotic outpatient antibiotic and addiction plans need to be dictated by the patient's clinical stability for both the ID realm and the addiction realm and really their needs.
Raagini Jawa:Right?
Raagini Jawa:Like it is a shared decision making venture.
Raagini Jawa:We can't be, uh, paternalistic about the.
Raagini Jawa:That, oh, this patient has an addiction and I can't discharge them on a PICC line because I could get sued.
Raagini Jawa:No, the patient has a cat or whatever that they need to take care of.
Raagini Jawa:They have work, they have kids, they have the same responsibilities that other patients with the past medical history of substance use disorder also have.
Raagini Jawa:Um, and, and we can't insert our morals or our own stigma into the clinical decisions that we make for this patient population.
Raagini Jawa:So I think that your, what w what kind of plan should we make?
Raagini Jawa:Well it should really be dictated by the patient and their clinical ID and addiction optimization.
Raagini Jawa:And my colleague, Dr.
Raagini Jawa:Ayesha Appa, who's also an infectious disease and addiction medicine provider.
Raagini Jawa:Um, from UCSF she summarized, uh, in the New England Journal Curbside Consult, uh, a fair amount of evidence about this, that while patients who use drugs face a lot of discrimination, um, on being discharged with pic lines, um, uh, again, I am an OPAT provider.
Raagini Jawa:Uh, for people who use drugs, I manage numerous patients with IV antibiotics and I don't see any contra-indication to discharge.
Raagini Jawa:Um, and this is not just because Doctor Jawa said, so this is actually evidence-based.
Raagini Jawa:Um, Dr.
Raagini Jawa:Laura Marks has shown that patients who are hospitalized with serious, um, invasive, bacterial infections who had patient directed discharges, who are on PO antibiotics, had high antibiotic adherence rates.
Raagini Jawa:So if they took their PO antibiotics, don't you think that also take their IV antibiotics?
Raagini Jawa:Like no one wins.
Raagini Jawa:If, if you don't take your medication and, and so that's really getting to the point that.
Raagini Jawa:It's not that patients at substance use disorder are a nonadherent.
Raagini Jawa:They also want to get better.
Raagini Jawa:And so, uh, they might just need a little bit more multidisciplinary, outpatient support.
Raagini Jawa:And then in terms of the literature that's shown.
Raagini Jawa:PICC line complications among people who use drugs while that's been mixed.
Raagini Jawa:And the data is like a lot of retrospective studies.
Raagini Jawa:And, um, and while some studies have shown increased vascular complications in this group of patients, there's really no significant difference between secondary line infections for patients who use drugs, who get home-based OPAT versus in-hospital OPAT.
Raagini Jawa:What all of these, you know, studies really show us is that.
Raagini Jawa:While there's a lot of variability in PICC line eligibility.
Raagini Jawa:Oftentimes it's dictated by what the institutional norm is.
Raagini Jawa:And sometimes the institutional norm is no that we will not.
Raagini Jawa:Um, but as medical providers who are providing evidence-based practices, I urge you to look at the most recent literature to guide some of your management and engage your patients in shared decision-making.
Raagini Jawa:Um, because there really isn't any negative outcome.
Raagini Jawa:It does require a fair amount of case management VNA buy-in, um, an outpatient sort of support for this patient population.
Raagini Jawa:But your clinic.
Raagini Jawa:Uh, decisions for this patient's outpatient management should not be dictated by anything except for, is this person optimized from their addiction?
Raagini Jawa:Yes or no.
Raagini Jawa:Is this person optimized for their infection?
Raagini Jawa:Yes or no.
Raagini Jawa:And then do they have like a stable way to get their IV antibiotics?
Raagini Jawa:Um, and that's it.
Raagini Jawa:And, you know, we can think about like tamper proof pick lines and all of these other sort of innovative ways to, uh, Prevent patients from utilizing their picks.
Raagini Jawa:But when you look at some of the qualitative literature that asks patients who use drugs on whether or not they inject in their pics, I mean, these patients are expert phlebotomist.
Raagini Jawa:They would not inject in their PICC and they say that they recognize the complications of injecting their PICCs are quite large.
Raagini Jawa:Um, they have other ways of injecting if they really needed to inject and if a patient wants to use, they will.
Raagini Jawa:Um, and I certainly have had a fair amount of patients who have triggers.
Raagini Jawa:They have cravings, they use, um, they perhaps use from a different route, they might use from a different arm, but that really, um, is your role to say, okay, that's still should not be a contraindication for them to get out of outpatient antibiotics.
Raagini Jawa:Um, that being said, I don't think that.
Raagini Jawa:IV antibiotics is necessarily the best route for everyone.
Raagini Jawa:Um, it is less optimal if you're not stably housed in the commentary that we wrote in Journal of Addiction Medicine, looking at the literature, there are some proposed criteria for consideration of
Raagini Jawa:outpatient antibiotics for people who inject drugs.
Raagini Jawa:It includes that the patient is willing to engage in close, follow up, that they, the patient has safe and stable housing.
Raagini Jawa:Even if this patient that we have in this case is not stable housed.
Raagini Jawa:Maybe they have a family member who's really engaged in their recovery that can house them that as a responsible adult.
Raagini Jawa:And then we'll continue to help.
Raagini Jawa:Administer the antibiotics and get them to appointments, et cetera.
Raagini Jawa:And I think that that should be included in the conversations that you have with your patients.
Raagini Jawa:I think that there's a lot of gray zones and, um, I encourage you all to have conversations with your patients.
Raagini Jawa:And Nathan, the other question you asked is, well, have antibiotics.
Raagini Jawa:In this day and age, our IV antibiotics really needed after two weeks.
Raagini Jawa:And we have data from POET really suggesting that for certain types of pathogens that you can do like a two week upfront IV antibiotic course, and it can be followed with a chaser of PO antibiotics.
Raagini Jawa:And, and this patient is lucky because they don't have a methicillin-resistant staph or is.
Raagini Jawa:Um, but you know, the POET trial didn't really include a lot of patients with substance use disorders.
Raagini Jawa:That being said the outcomes for, from the more sensitive pathogens was probably fine.
Raagini Jawa:Um, so I really think it's dependent on what your ID consultants in your institution are comfortable doing.
Raagini Jawa:There are other trials about long-acting lipo, um, glycopeptides and whatnot that can help.
Raagini Jawa:Um, facilitate patients being able to go home earlier, uh, that, uh, yeah, uh, I think the world is our oyster.
Raagini Jawa:Um, the way we provide care to this patient population is very much changing and, and it should change because, uh, there's really no reason for these patients to not get standards of care that we provide to every other patient who doesn't have the past medical history stamp of an addiction.
Raagini Jawa:Um, I will tout this, this a paper that came out in JAMA Open Network, we simulated the cost-effectiveness and long-term clinical outcomes of addiction care and antibiotic therapy strategies for patients with injection drug use associated endocarditis.
Raagini Jawa:And if you model, if this is a cost-effective strategy to discharge patients on partial oral antibiotics, um, and outpatient IV antibiotics with a combination of addiction care.
Raagini Jawa:It is a cost-effective strategy.
Raagini Jawa:And so if you're getting a lot of pushback from your hospital systems or your VNH or your case management saying like, I don't feel comfortable, this isn't a good idea.
Raagini Jawa:This might be a waste of our money.
Raagini Jawa:Well there's data that suggests that it might actually be a cost saving venture for the hospital system.
Raagini Jawa:And ha heck, it'll be a real, real benefit for our patients.
Raagini Jawa:Patients who inject drugs are just like every other patient that we take care of.
Raagini Jawa:They should be getting the same standard of care and should not be discriminated against, um, forgetting serious bacterial and fungal infections.
Sara Dong:Hi, everyone.
Sara Dong:Thanks again for listening to Febrile, we will put links to tons of resources about the topics that we covered in today's episode.
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