Episode 99
99: StAR: Frame Shift
This StAR episode features the CID State-of-the-Art Review: Frame Shift – Focusing on Harm Reduction and Shared Decision Making for People Who Use Drugs Hospitalized with Infections.
Our guest stars this episode are:
Dr. Kinna Thakarar (ID and Addiction Medicine physician at MaineHealth/Tufts University School of Medicine)
Dr. Ayesha Appa (ID and Addiction Medicine physician at University of California San Francisco, UCSF)
Chastity Tuell (Harm reductionist and Washington County Program Director for Maine Access Points)
Journal companion article - Executive summary link: https://academic.oup.com/cid/article/78/2/233/7453720
From Clinical Infectious Diseases
Episodes | Consult Notes | Subscribe | Twitter | Merch | febrilepodcast@gmail.com
Febrile is produced with support from the Infectious Diseases Society of America (IDSA)
Transcript
Hi, everyone.
Speaker:Welcome to Febrile, a cultured podcast about all things infectious disease.
Speaker:We use consult questions to dive into ID clinical reasoning, diagnostics,
Speaker:and antimicrobial management.
Speaker:I'm Sara Dong, your host and a MedPeds ID doc.
Speaker:Welcome to the next Febrile StAR episode.
Speaker:These will feature topics and authors from the CID Journal's
Speaker:State of the Art Reviews.
Speaker:You can listen to episode number 97 for a quick introduction from the
Speaker:editors of these reviews, and this is our second of four straight weeks of
Speaker:StAR episodes to kick off the series.
Speaker:All right, I'll introduce our guest stars today.
Speaker:Dr.
Speaker:Kinna Thakarar is an associate professor of medicine at Maine Health and
Speaker:Tufts University School of Medicine.
Speaker:She is an infectious diseases and addiction medicine physician.
Speaker:Her clinical and research interests include the ID and substance use syndemic,
Speaker:particularly harm reduction, shared decision making, and community based work.
Speaker:Hi there.
Speaker:This is Kinna Thakarar, and I am super excited to be here today.
Speaker:Dr.
Speaker:Ayesha Appa is an assistant professor of medicine at the University of California
Speaker:San Francisco, UCSF, where she completed ID and addiction fellowships in 2023.
Speaker:Her research and clinical priorities are on patient centered models of
Speaker:care for simultaneous treatment of addiction and infections including HIV.
Speaker:This is Ayesha Appa and similarly, psyched to join this crew.
Speaker:Chasity Tuell is a harm reductionist and serves as the Washington County
Speaker:Program Director for Maine Access Points.
Speaker:Maine Access Points is a harm reduction organization providing syringe access
Speaker:services, overdose prevention education, and naloxone distribution, peer support,
Speaker:and advocacy throughout rural Maine.
Speaker:This is Chasity Tuell.
Speaker:Thanks for having me today.
Speaker:Thank you guys so much for joining.
Speaker:Before we talk about the awesome cases today, we're gonna intro as
Speaker:everyone's favorite culture podcast.
Speaker:I would love to hear about a little piece of culture, basically something
Speaker:non medical that brings you joy.
Speaker:Mine is a bit random.
Speaker:So I grew up in the Philadelphia area and one thing that makes me
Speaker:really happy when I go home is Wawa coffee and a pretzel, a soft pretzel.
Speaker:I don't know if, if folks don't know what Wawa is.
Speaker:Some may refer to it as like a convenience store, but I like to
Speaker:joke that it's really a lifestyle.
Speaker:And one fun fact actually is that my parents, their first date was actually
Speaker:what is now a Wawa in West Philly.
Speaker:And so I think it's just hilariously like symbolic of our, our Wawa.
Speaker:That's beautiful.
Speaker:I could, I can go, my - I was trying to think about culture apart from the
Speaker:noise from my two toddlers that involves like Peppa Pig and things like this.
Speaker:Um, mine is not highbrow, but I was just on vacation and was a little late to this
Speaker:party but read Fourth Wing, which is this book that is this combination of Harry
Speaker:Potter and Hunger Games and also with a sort of like spicy romance element.
Speaker:I flew through that.
Speaker:So, good escapist rec for anyone.
Speaker:Right now one of my favorite joys has like really been junior high sports,
Speaker:which sounds so weird, but we're so invested in it at the moment, and
Speaker:being able to see how much the kids are changing and gaining confidence
Speaker:throughout the year has been so fun.
Speaker:And I've, realized I've turned into one of those people who just
Speaker:like randomly is looking at kids smiling so proud of them and then
Speaker:realizing like, I look like a freak.
Speaker:That's definitely it right now.
Speaker:Oh, I love it.
Speaker:Oh, thank you guys for sharing those.
Speaker:You know, I'm really excited to have you here.
Speaker:We're going to chat about your state of the art review, uh, which is entitled
Speaker:Frame Shift, Focusing on Harm Reduction and Shared Decision Making with People Who
Speaker:Use Drugs Hospitalized with Infections.
Speaker:I thought I would actually just ask if we could start with giving an introduction,
Speaker:the things that you were thinking about as you were crafting this article.
Speaker:Well, first I should give a shout out to the editorial team at CID
Speaker:for actually inviting us to do this state of the art review.
Speaker:You know, it was really meant to not just cover
Speaker:clinical presentation and management for people who use drugs, but
Speaker:they really wanted us to have like an intentional focus on shared
Speaker:decision making and harm reduction and approaches to reducing health
Speaker:inequities for people who use drugs.
Speaker:So, you know, with that, we, we consciously developed
Speaker:a multidisciplinary team.
Speaker:So, obviously, there's Chastity and Ayesha here today, but we also,
Speaker:our team included a PharmD, Jacinda Abdul-Mutakabbir, an addiction medicine
Speaker:nurse practitioner, Amelia Goff, and LCSW, Jess Brown, and then also actually
Speaker:my own mentor, Kathleen Fairfield, who's an expert in shared decision
Speaker:making, and of course, our amazing ID scientist colleague, Alysse Wurcel.
Speaker:What we did is we created some clinical cases to really illustrate a spectrum
Speaker:of fairly common scenarios, I think, and we provided viewpoints, especially
Speaker:where we don't have robust data.
Speaker:So, in the review, we tried to offer strategies for ID clinicians to use that
Speaker:really incorporates tenets of shared decision making and harm reduction.
Speaker:Before we dive into the cases, too, it's probably helpful to understand some of the
Speaker:barriers that people who use drugs face.
Speaker:So, I'm hoping, Chasity, maybe if you wanted to weigh in on this and just
Speaker:given your experiences in the field.
Speaker:Of course, so I am in very rural Maine and there's so much context in that.
Speaker:The landscape of the way the state is, so much is rural and we have to travel
Speaker:so far for anything and everything, not even just the length of travel.
Speaker:There's very limited, if any, public transportation.
Speaker:My area, we don't even have a taxi.
Speaker:There's a lot to think of there, so it makes it really challenging
Speaker:to get folks to appointments and anywhere they need to be.
Speaker:With that too, there's like a lot of the small town stigma that people face.
Speaker:I know that I have a lot of participants I encounter that won't go to the emergency
Speaker:room or won't go to local providers because someone they know that works
Speaker:there, or a family friend, or they had a rough couple of years in life,
Speaker:now they're excelling, but they're By their past in this really harmful way,
Speaker:a lot of times I think in policies and just decision making in general,
Speaker:those pieces don't get thought about.
Speaker:And it is such a huge piece of if people will choose or not choose to
Speaker:get the care that they really need.
Speaker:That's such good perspective.
Speaker:I think from like contextually, as I'm rooted in San Francisco
Speaker:on the other side of the country in a very urban environment.
Speaker:I don't often think about that with a small town perspective, though people
Speaker:who use drugs and are folks that we're interested in talking about today, what
Speaker:I hear is similar fear of discrimination.
Speaker:In that folks are using the same county hospitals or same couple of safety net
Speaker:institutions, and whether it's stigma and discrimination, really, that they've
Speaker:faced related to using drugs, or whether it's race, ethnicity, sexual orientation,
Speaker:sex or gender, approaching or, or really circumventing that takes a lot of courage
Speaker:on the part of people who use drugs when they've faced that in the past.
Speaker:And so that is, is one barrier is like even getting in the door and then in the
Speaker:line of sort of inequity and diagnosis and prevention and management of both
Speaker:infections and substance use disorders.
Speaker:It really like runs the gamut of, Implicit bias in prescribing antimicrobials
Speaker:or structurally racist policies that have sort of segregated our
Speaker:medications for opioid use disorder.
Speaker:There's just a lot of intersectionality really in creating these
Speaker:overlapping systems that can make it tough to get really good care.
Speaker:Also, maybe before we kick off with the cases, I'm sure most people know
Speaker:what harm reduction and shared decision making are, but maybe it would be
Speaker:helpful just to give a brief overview.
Speaker:Chasity, would you want to go over the definition of harm reduction.
Speaker:So harm reduction by definition, and you will see this in all policies now,
Speaker:is a set of practical strategies and ideas aimed at reducing the negative
Speaker:consequences associated with drug use.
Speaker:It was also built on a social justice movement for and by people who use drugs.
Speaker:In practice, that is autonomy, letting people have the right and
Speaker:the choice to what is best for them.
Speaker:Yeah, thanks for that.
Speaker:And I think, you know, from a clinical perspective, too, Ayesha,
Speaker:feel free to weigh in, but, you know, I think a harm reduction based
Speaker:approach to treating people who use drugs is really just so important.
Speaker:Just like what you said, you know, patient autonomy and making sure
Speaker:they're included in treatment plans.
Speaker:You know, that's where I think shared decision making comes in too.
Speaker:It's really a collaborative process where really, you know, the patients and their
Speaker:values are at the center of the decision.
Speaker:And so, I think we're just seeing more and more of that in treatment guidelines
Speaker:and especially where there's evidence that's still emerging or ambiguous.
Speaker:Harm reduction and, and shared decision making can be really
Speaker:helpful when we're caring for people.
Speaker:My simplistic take on it is that harm reduction is radical love.
Speaker:Like you're just like really trying to like see that person where they are and
Speaker:say like, I appreciate you for coming at whatever phase of change or not change.
Speaker:You are, you are just a human in front of me that I will
Speaker:help be as healthy as possible.
Speaker:All right.
Speaker:Are you guys ready to jump in with our example scenarios?
Speaker:Yeah, let's do it.
Speaker:Awesome.
Speaker:And all of these, I have to say as the reader of the paper that you've
Speaker:created, all of them feel familiar.
Speaker:I feel like all of these examples were things that I have participated
Speaker:in or, or been a part of.
Speaker:So our first scenario is we meet a 35 year old woman who is hospitalized
Speaker:for one week of fevers and rigors.
Speaker:She had taken a couple of days of doxycycline that she had received
Speaker:from a friend prior to coming in.
Speaker:On admission, her blood cultures from the ED demonstrate Streptococcus
Speaker:mitis, and then further workup identifies a dental infection.
Speaker:Ultimately, she has three days of bacteremia.
Speaker:Her co occurring conditions include anxiety, opioid use disorder,
Speaker:and a history of IV drug use.
Speaker:Her current treatment includes methadone and attending recovery group.
Speaker:She has no recent drug use or cravings.
Speaker:For a little bit more clinical info, the TTE and TEE were negative for vegetation.
Speaker:There's been no signs or symptoms of infective endocarditis.
Speaker:She successfully undergoes a dental extraction and during the admission, her
Speaker:home dose of methadone is continued and she attends her recovery group meetings
Speaker:virtually during the hospitalization.
Speaker:So now it's four days or so later, and she expresses to you
Speaker:her desire to be discharged home.
Speaker:She wants to be home with her children and complete the rest of the course
Speaker:with IV antibiotics because I didn't mention this, but she had been unable
Speaker:to tolerate some of the oral antibiotics that were tried during her admission.
Speaker:You know, she tells you, I feel like I can safely care for my PICC line at home.
Speaker:She's eligible for home health services and, and shares that she understands
Speaker:the risks of incomplete treatment and has really good family support.
Speaker:So how would you guys approach this scenario?
Speaker:Let's see.
Speaker:Well, Chasity, would you want to weigh in maybe a little bit before we dive
Speaker:into the management and maybe just thinking about potential barriers
Speaker:she may have faced in coming to the hospital that could have impacted her
Speaker:care, or things we could do better.
Speaker:Well, as it was asked, who wants to take this?
Speaker:I was thinking, I'm not a doctor, these questions aren't for me.
Speaker:But I can see myself on the other side of it, like as the patient,
Speaker:Yes.
Speaker:So important.
Speaker:There's so many pieces like, and I think as a mother also that is
Speaker:relevant, like we put off our own care to take care of our family.
Speaker:So that's adding just another level of barrier to this.
Speaker:So it's difficult to try and go take care of yourself,
Speaker:especially if you have children.
Speaker:And if there's been any negative experiences, and I think at some point,
Speaker:everybody has had a negative health care experience, even very minor, all
Speaker:of that weighs on us being on methadone, that's already so high barrier for
Speaker:people in any ways, because there's so much asked of them to go daily, multiple
Speaker:times a week, whatever it is, it's so restrictive and it takes so much time
Speaker:and takes away from our family, our jobs, and all of our responsibilities,
Speaker:it is really difficult to get yourself to the point to go to the hospital
Speaker:and have to spend so much time there.
Speaker:Other people that haven't lived through any of this think
Speaker:that just sounds ridiculous.
Speaker:Like.
Speaker:Well, you have to take care of yourself.
Speaker:And it's like, yeah, we do, but there's also all of these other
Speaker:pieces people aren't thinking about.
Speaker:I know it's very easy to dole out the advice and then think about like, oh, yes,
Speaker:how am I getting to my own appointment?
Speaker:I can barely hold this together.
Speaker:Like, how are we expecting this person with dependence and a daily need
Speaker:to go to a clinic to do all this?
Speaker:Getting back to your question, Sara, of like, of how do you manage this scenario?
Speaker:Or how do you approach this??
Speaker:If there's one thing that you remember from this case, I'd want it to be that
Speaker:substance use is not a contraindication to discharging people home with OPAT.
Speaker:It's really easy for us to look at the chart and say like history of IDU
Speaker:and have that color this person's care going forward in perpetuity, but being
Speaker:a part of this article was a really nice opportunity to dive into this
Speaker:grey area and really help people work with their patients to make a decision
Speaker:about the best treatment strategies.
Speaker:In this case, this person is someone with opioid use disorder in remission
Speaker:who's on methadone, who hasn't described recent injection drug use.
Speaker:And so it is someone in whom I'm not so worried about the risks of,
Speaker:say, secondary bacteremia related to injecting through a PICC.
Speaker:I am really not worried about life chaos that might be associated with some people
Speaker:who are using and, say, experiencing homelessness or using stimulants, etc.
Speaker:This is somebody who's housed with kids.
Speaker:She's getting a lot of stuff done for her.
Speaker:And so, broadly, consider OPAT for people using substances, and then be specific
Speaker:about what, what the concern might be if there is one related to substance use.
Speaker:We go into some of these data in our article.
Speaker:Joji Suzuki and colleagues from Partners did a really nice review published
Speaker:in OFID looking at essentially the data quantifying adverse events or
Speaker:successful completion of OPAT in people injecting drugs or using drugs.
Speaker:And so I'd refer to that in our section of that article if you're
Speaker:feeling the need to be bolstered.
Speaker:The other thing too I sometimes bring up with folks if you do get pushback
Speaker:is like if they're being denied OPAT.
Speaker:I mean, that It could be considered, you know, a violation of the Americans
Speaker:with Disabilities Act or the ADA, and so, I mean, I'm not a lawyer,
Speaker:obviously, but what is recommended is you, there are ways to, you know,
Speaker:file a report, and we just, like, have to advocate in situations like this.
Speaker:So, but I totally agree with everything that s been said.
Speaker:One other thing in terms of management is, you know, how to incorporate
Speaker:shared decision making for this case.
Speaker:You know, I think we know, we all know that these prolonged hospitalizations
Speaker:can be really harmful for patients and some clinicians, though, may perceive
Speaker:that being in the hospital, you know, it's a protective environment, but the
Speaker:reality is, you know, people they want to use drugs are going to use it, you
Speaker:know, even if it's in the hospital and like Chasity said, they, you know, folks
Speaker:have families or job responsibilities.
Speaker:And so they may not want to be there for that long.
Speaker:And so they can also, you know, have stigmatizing encounters
Speaker:or get nosocomial infections.
Speaker:So I think it's really on us to really, you know, meet with each patient and
Speaker:everyone's going to have different values and preferences and goals and really try
Speaker:to incorporate shared decision making.
Speaker:You know, one thing I've heard from colleagues.
Speaker:I was like, oh, it's it's so time consuming.
Speaker:And so, you know, we have borrowed from the palliative care field where they
Speaker:use the serious illness conversation guide, which is really considered
Speaker:best practices in palliative care.
Speaker:And so there's not much data in people who use drugs.
Speaker:So in Maine, we actually ended up building on shared decision making
Speaker:and this conversation guide to develop and implement a guide that
Speaker:was specific to people who use drugs.
Speaker:And I mean, it was pretty well received.
Speaker:It was a small pilot study.
Speaker:Obviously we need more data and more research, but it was really promising
Speaker:and it was a way to really incorporate patient preferences, discussing treatment
Speaker:options and tradeoffs for different approaches, and then just, you know,
Speaker:closing the conversation, documenting it, and communicating with physicians.
Speaker:So in this particular case, though, you know, we recommended in the review
Speaker:to have this, you know, structured conversation, understanding this patient's
Speaker:preferences, and you know, she has a good understanding of her infection and
Speaker:the different treatment options, also has stable housing, family support.
Speaker:So, we recommended that the primary team consider discharging her home with OPAT,
Speaker:you know, the methadone environment is pretty restrictive in terms of
Speaker:the regulatory environment right now.
Speaker:And so, if this patient has to go to the methadone clinic every day,
Speaker:you know, considering something like ceftriaxone once a day, just so that
Speaker:doesn't interfere with her going to and from the methadone clinic.
Speaker:Totally.
Speaker:I was going to say the exact same thing as like that concrete pearl for ID providers.
Speaker:It's like know your patient's lives.
Speaker:And again, this applies to everything, not just people who use, but, but, you
Speaker:know, know their lives and what fits in.
Speaker:I think OPAT providers are really good at trying to select antibiotics that
Speaker:will be least burdensome, and that's like particularly true, I think, with
Speaker:thinking about how methadone fits in.
Speaker:Excellent.
Speaker:Okay.
Speaker:So we're going to go on to our next scenario.
Speaker:This time we meet a 44 year old male who injects fentanyl and is
Speaker:experiencing homelessness after recently being released from jail.
Speaker:He's currently hospitalized with MRSA mitral valve endocarditis.
Speaker:So there's a 0.
Speaker:5 centimeter mitral valve vegetation noted on TEE with no other abnormalities.
Speaker:So the multidisciplinary endocarditis team recommends medical management.
Speaker:The inpatient addiction consult service diagnosed him with opioid use disorder
Speaker:and the patient identifies his goal as abstaining from further fentanyl use.
Speaker:In hospital, they initiate methadone with a plan to up titrate while he is there.
Speaker:He meets with a licensed clinical social worker to help
Speaker:facilitate housing applications.
Speaker:And after about four weeks in the hospital, the patient feels that
Speaker:he is at a stable methadone dose.
Speaker:He is not experiencing significant cravings.
Speaker:And though he has not yet secured housing, he starts to express
Speaker:his desire to leave the hospital.
Speaker:He does not want to be discharged with a PICC, but does want his infection
Speaker:to be treated the best that it can.
Speaker:And the other additional piece of information is that he does have a sulfa
Speaker:allergy with a history of anaphylaxis and his medication list includes sertraline.
Speaker:What do you guys think?
Speaker:How should we approach this case?
Speaker:Thanks, Sara.
Speaker:I am, in thinking about this case again, just feeling really thankful that we
Speaker:are where we are today, even if we have a long way to go, and like, really
Speaker:delivering equitable care to people who use drugs, you know, in this case, we are
Speaker:taking care of somebody who is admitted to a hospital with an addiction consult
Speaker:service, which may not be the standard for every hospital in the country.
Speaker:And again, this is specific, but this is a very different clinical stem than, let's
Speaker:say, I think patients that I was seeing in residency not so, so long ago in 2015.
Speaker:There's this implicit understanding in the stem you presented that treating
Speaker:addiction should be standard of care when managing infectious complications of drug
Speaker:use, or when really just like seeing a patient with a substance use disorder at
Speaker:a touch point that is the hospitalization, thinking about, you know, what can we do
Speaker:in a wraparound way to treat this person's addition, how can we advance their care
Speaker:and really treat the root cause of this infection and prevent further infections
Speaker:is the standard, which is fantastic.
Speaker:Generally, he's gotten a diagnosis of opioid use disorder, gotten
Speaker:started on methadone, which is fantastic and is getting uptitrated.
Speaker:When I see that he's at a stable methadone dose after four weeks in
Speaker:the hospital, that's another huge win.
Speaker:This is somebody who stayed in the hospital or, you know, in a supervised
Speaker:setting for a month whose dose was up titrated effectively, which is often,
Speaker:you know, we're often seeing folks leave potentially in the setting of meds for
Speaker:opioid use disorder not even being started or offered, or doses not being adequate
Speaker:enough to address either withdrawal or cravings and really get to a stable dose.
Speaker:Those are wins in the stem and things that I encourage anybody listening
Speaker:to, to make sure are in place in your medical settings that you have
Speaker:a way of offering buprenorphine and methadone for opioid use disorder and
Speaker:thinking carefully about what your, what your resources are for stimulant
Speaker:use disorder and all use disorders that may be related to someone's infection.
Speaker:The last thing I'll just say about that broadly is I know that the access
Speaker:to methadone is really fragmented and different across the country.
Speaker:And so there may be, I think there are opportunities for advocacy on the
Speaker:individual systems level, or like medical, medical center level, you know, up
Speaker:through state and federal levels here.
Speaker:Kinna, maybe I'll ask you your approach to, we have some specific
Speaker:information about where he is in his course of endocarditis treatment,
Speaker:and I'm curious how you approach the antibiotic prescribing options.
Speaker:This also gets back to the, you know, conversation guide and making sure that
Speaker:we offer any quote unquote non traditional options, so that could include long acting
Speaker:antibiotic infusions and oral antibiotics.
Speaker:So, you know, for this case, he's made it, you know, pretty clear he doesn't
Speaker:want to PICC but we could discuss dalbavancin or oral antibiotics.
Speaker:In the interest of time, I'm not going to go through all of the options,
Speaker:but you can read in the review.
Speaker:But also, you know, I think it was Dr.
Speaker:Baddour and actually Dr.
Speaker:Wurcel as well.
Speaker:They have a really great paper and It was published in Circulation, I believe, in
Speaker:2022 that really summarizes very well, sort of, going through the feasibility
Speaker:of these different options for people who use drugs with endocarditis.
Speaker:So, I definitely recommend reading that.
Speaker:But I think just generally, you know, thinking about each option, you know, for
Speaker:this patient, do they have transportation to get to a center where he can get a
Speaker:long acting injectable like dalbavancin?
Speaker:Obviously, you know, there's still RCTs going on to look at dalbavancin
Speaker:in infective endocarditis, but there's really promising data.
Speaker:Also talking about oral antimicrobials in this case would be relevant and
Speaker:we should definitely do that for this patient just knowing his goals.
Speaker:At the end of the day, thinking about structural drivers of health
Speaker:and the feasibility of treatment options should be prioritized.
Speaker:And I think the other big discussion point that we had in the paper is
Speaker:also making sure that we prioritize treatment for substance use, looking
Speaker:at any drug drug interactions, because we know that there are certain touch
Speaker:points where people are at very high risk for overdose, and sadly, discharge
Speaker:from the hospital is one of them.
Speaker:And so, if patients want to go on treatment, I think we need to
Speaker:do our best to, like, make that transition as smooth as possible.
Speaker:So, just as like a concrete example here for this case, thinking about the
Speaker:POET trial, for example, they looked at linezolid and rifampin, but we
Speaker:know that rifampin can markedly reduce methadone levels and may, you know,
Speaker:reduce buprenorphine levels, and so would we want to perhaps consider rifabutin
Speaker:instead of rifampin or just, you know, go with linezolid monotherapy knowing that
Speaker:there may be, you know, limited data.
Speaker:So I think it's just talking about these tradeoffs and options openly
Speaker:with patients is best practice, but And it's probably obvious, but I think
Speaker:it's important to also say that we should, we recommend, again, stopping
Speaker:substance use treatment like methadone and buprenorphine just to accommodate,
Speaker:you know, antimicrobial options.
Speaker:The other unique thing about this case is him being in a rural state, right?
Speaker:So I think we know that rural areas are really disproportionately burdened
Speaker:by substance use and drug overdose deaths, and people have limited
Speaker:access to certain types of care.
Speaker:So, I don't know, Chasity, if you want to weigh in here a little bit for this
Speaker:case too, because since you work in one of the most rural counties in the U.
Speaker:S.
Speaker:Yeah, I was looking at it and thinking about the fact that they
Speaker:still haven't secured housing and they're in rural Maine.
Speaker:There's so many layers to that.
Speaker:They're going to need to get to their clinic, and since they're a new patient,
Speaker:they're going to have to go often.
Speaker:But they also don't know where they're sleeping, so adding any
Speaker:restrictions on treatment is going to make everything in their life harder.
Speaker:We have to travel really far, and we don't have shelters, so we do
Speaker:a lot of couch surfing, and we don't even have, um, encampments
Speaker:like you have in bigger cities.
Speaker:So, as terrible as that is, there's no sense of community for the people
Speaker:experiencing homelessness in rural Maine.
Speaker:So, it's really isolating.
Speaker:So, I think in cases like this, just being able to connect folks to people
Speaker:that are already embedded in the community is really, really important.
Speaker:And then they have another touch point for anything that they need.
Speaker:We're, we're small town Maine.
Speaker:If we don't have an answer, we know who has the answer.
Speaker:I love that.
Speaker:One other thing that I'll just add around the drug drug interaction point.
Speaker:I agree.
Speaker:I hope most people aren't in a cavalier fashion stopping methadone
Speaker:or bupe, but I've had many a good conversation with folks about
Speaker:like, you know, the rifampin is
Speaker:important.
Speaker:And that's what's evidence based.
Speaker:Our data for rifabutin are poor or our data for monotherapy or some of these
Speaker:alternative options are not there.
Speaker:And, and so like, can't we just increase the methadone?
Speaker:Of course there are many options on the table, but disrupting someone's
Speaker:stable methadone dose with PK that's like really unreliable, like that
Speaker:you cannot really predict when, if any, and to what degree someone's
Speaker:effect will, will be felt from that.
Speaker:Induction via rifampin is incredibly destabilizing.
Speaker:I've seen a number of patients who've been on RIF and didn't really
Speaker:understand what was going to happen and returned to use and again,
Speaker:really destabilizing in their lives.
Speaker:So would really prioritize maintaining that methadone whether it's drug drug
Speaker:interaction wise, or just the act of, of, of going, um, and, and having a
Speaker:conversation with your patients, with your addiction medicine colleagues, if,
Speaker:if there's questions to, to get at that.
Speaker:Great.
Speaker:All right.
Speaker:And I'll move us forward to our next scenario.
Speaker:This time we meet a 35 year old transgender woman who is
Speaker:experiencing homelessness.
Speaker:She is admitted with pan susceptible Serratia bacteremia in the setting of
Speaker:IV fentanyl and methamphetamine use.
Speaker:She has been injecting drugs with non sterile water, shares needles, given there
Speaker:is no access to a syringe service program in her primarily Black neighborhood.
Speaker:The patient occasionally engages in primary care through
Speaker:a local mobile health unit.
Speaker:She is not currently interested in outpatient substance
Speaker:use disorder treatment.
Speaker:Her bacteremia is initially treated with cefepime, and opioid withdrawal
Speaker:is treated with short acting opioids.
Speaker:Two days into her hospitalization, She decides to leave the hospital.
Speaker:It's midnight and you get a call to ask for help on, on how to move forward.
Speaker:So I will say that the, you know, goal of having structured conversations
Speaker:about treatment options and their trade offs is to hopefully minimize
Speaker:unplanned discharges like this and, you know, talking about oral antibiotic
Speaker:options and, um, documenting them and putting it in the chart so that cross
Speaker:covering teams can use that information if an unplanned discharge happens,
Speaker:you know, that's the ideal situation.
Speaker:But that being said, you know, unplanned discharges can happen and oftentimes
Speaker:it feels like it's always at midnight or overnight and there is a really
Speaker:great, it was a single site study, I think by Laura Marks and colleagues,
Speaker:where they showed that at least offering oral antibiotics compared to
Speaker:no antibiotics had better outcomes.
Speaker:So, I think at the end of the day, the take home point here is like, there's
Speaker:always something we can do for patients on discharge, whether that's, you know,
Speaker:oral antibiotics, naloxone, or, you know, something I always talk about
Speaker:with trainees is just contact us and we can still get, you know, expedited
Speaker:telehealth or follow up ID visits.
Speaker:In Maine, we work very closely with our homeless health partners.
Speaker:So, we'll just message them afterwards to try to arrange follow up and in
Speaker:Laura Marks' study, they looked at how those follow up visits were really
Speaker:helpful for discussing PEP or PrEP and harm reduction counseling, making sure
Speaker:they actually got their antibiotics if they were discharged or, you know,
Speaker:whatever other help they needed.
Speaker:Just recognizing that, especially for this case, there are still things that
Speaker:we can do to really, you know, optimize this patient's health and safety.
Speaker:So, the hospital really can be an opportunity for, infectious
Speaker:disease screening and prevention.
Speaker:So when this patient is hospitalized, it'd be great to go through, like,
Speaker:how does, how is she using drugs?
Speaker:Um, does she have access to syringe services programs, naloxone, and
Speaker:talking about screening for STIs, PEP and PrEP, all the things, and,
Speaker:you know, seeing if she has access to local harm reduction organizations.
Speaker:And the other part of this, I think, too, is making sure folks, you know, offering
Speaker:screening for HIV, other STIs, including extragenital testing, CDC really says,
Speaker:you know, annual testing, but I think in this review we said at least every
Speaker:three months or even more frequently depending on how people are using,
Speaker:right, if they're sharing equipment.
Speaker:Maybe they need, you know, more frequent screening.
Speaker:Also, for this patient early on, we tried to offer her vaccines.
Speaker:Here in Maine, actually, we're seeing, we have some of the highest
Speaker:rates of acute Hep B and are having clusters of Hep A infections now.
Speaker:So, offering, you know, Hep A and B vaccines, Tdap, Prevnar, COVID, all
Speaker:the things and, you know, we know that even 1 dose of hepatitis vaccine
Speaker:can provide some coverage and you don't have to wait for serologies.
Speaker:That's per CDC guidelines and so trying to offer all of these things as
Speaker:early on as possible so that if they do leave early, you know, there are
Speaker:some preventive strategies in place.
Speaker:I think this can be like a lot, somewhat overwhelming to think about.
Speaker:So I think like, if you have a way to do this systematically,
Speaker:wherever you practice, it's helpful.
Speaker:You know, like in Maine, we have a little checklist in EPIC.
Speaker:We have a smart phrase that we use and, you know, folks have done some studies
Speaker:on bundled interventions and toolkits and it is feasible, I think, to, to do this.
Speaker:Yeah.
Speaker:I really just want to underscore how validating, or I think like
Speaker:offering those, I was going to say harm reduction screenings, but it's
Speaker:really just general health screenings.
Speaker:And again, that sort of no wrong door opportunity to offer screening and
Speaker:testing for things that, you know, you may have done in a clinic setting, but
Speaker:again, like someone's here accessing services, like how can we offer it?
Speaker:It can be just a beautiful start to a conversation with someone that feels
Speaker:It's very validating, like, ah, yes, you're not going to push treatment
Speaker:on me because that's not what I'm interested in, but you're going to try
Speaker:to optimize my health and know that I care about my health regardless.
Speaker:It's really easy when we've gone through medical training that's like heavily
Speaker:inpatient and you're doing these like blocks of time in the hospital and
Speaker:then maybe you have like little smidges in between of clinic, like you really
Speaker:think about life as like the hospital and then the clinic, but patients are
Speaker:not experiencing life that way, right?
Speaker:Like they're, they're going in and out and this, like this is their life and
Speaker:their health and they're contending with doctors in different places, but
Speaker:it's really the infection or the XYZ cause of hospitalization, not the care
Speaker:setting that they're orienting around.
Speaker:And so it's really artificial that we orient ourselves that way.
Speaker:If we want good outcomes in, in people who use drugs, like we have to understand,
Speaker:like, where might they be going afterwards or are used to going or, or how can
Speaker:we work with, whether it's community based organizations, syringe access
Speaker:programs, or just models of care in clinic, you know, in our institution,
Speaker:we have our, our HIV clinic, Ward 86, has a drop in model serving people
Speaker:experiencing homelessness called pop up.
Speaker:You can come in anytime.
Speaker:There are no appointments as, as there are similar sites sort of around the
Speaker:city, and I know around the country, if you are that person in the hospital
Speaker:thinking about, what are my resources?
Speaker:Like, who can I figure out that I can contact for this patient, to help them
Speaker:land more seamlessly, that would be one thing, and the other, I would say,
Speaker:is when thinking about that person leaving at midnight, as again, as
Speaker:Kinna said, like, we're going to try to figure out an oral antibiotic plan
Speaker:or some antibiotics better than none.
Speaker:The other thing that I don't think is too much to ask is, like, thinking
Speaker:about what harm reduction interventions you can offer, whether it's
Speaker:naloxone at bedside or at discharge.
Speaker:Our hospital recently started doing, like, providing safe
Speaker:consumption supplies at discharge.
Speaker:Leah Fraimow-Wong and team published this recently, JAMA Network Open, that's
Speaker:looking at, you know, how much patients and other stakeholders valued that.
Speaker:I'm really glad to hear you guys are giving out supplies
Speaker:to people at discharge.
Speaker:That was one of the things that really stood out to me in this.
Speaker:Like, why can't people just get what they need when they leave?
Speaker:It, it's medical supplies, so they should be able to get it.
Speaker:And the fact that this patient meets with a mobile health unit, that seems
Speaker:like such a missed opportunity to not have a syringe service program
Speaker:embedded there, or partnered there, anything low barrier is It's always
Speaker:going to be the best way to get people.
Speaker:People need community.
Speaker:Having low barrier services in the community instead of in
Speaker:the hospital setting is always going to be what folks need.
Speaker:Thanks Chasity.
Speaker:Well, I will round us out with our last scenario here.
Speaker:Um, this time we meet a 25 year old man.
Speaker:He is experiencing homelessness with chronic hepatitis C virus, opioid
Speaker:and stimulant disorders, and recent MSSA prosthetic valve endocarditis.
Speaker:He is receiving IV cefazolin through a PICC line at a local
Speaker:medical respite care center.
Speaker:Through the care center, which serves people experiencing housing
Speaker:insecurity, he can receive this continuous care, so IV antibiotics,
Speaker:following his hospital discharge.
Speaker:So, his additional treatment includes methadone for opioid use disorder
Speaker:and mirtazapine for stimulant use disorder, as well as counseling.
Speaker:Four weeks into treatment, he's still unable to secure housing and discovers
Speaker:that he has lost his job permanently.
Speaker:The respite care staff are alerted that a nurse found a syringe in his bed.
Speaker:There is concern that he had used his PICC to inject
Speaker:methamphetamine over the weekend.
Speaker:Otherwise, he is hemodynamically stable, doing well, and just prior
Speaker:to his scheduled ID follow up appointment that week, the respite
Speaker:care staff call and ask how they should proceed with his treatment.
Speaker:This is a tough scenario.
Speaker:Again, as in the other case, there are many things I think that this
Speaker:is going well here and that this is someone who is receiving shelter and
Speaker:is four weeks into his antibiotics on methadone and sort of interested in
Speaker:help for reducing his stimulant use.
Speaker:The approach that I take to learn more about ongoing substance use
Speaker:on addiction treatment and on infection treatment that may involve the PICC is
Speaker:first starting by setting the scene well, making sure that you have the time and
Speaker:space to have a conversation that's, you know, 15, 20 minutes longer, sit down,
Speaker:look your patient in the eye, hopefully you have developed a relationship,
Speaker:and then ask permission to have a conversation about ongoing substance use.
Speaker:And that may look like, hey, do you have a minute, a few minutes, like that.
Speaker:Can we talk a little bit about drug use.
Speaker:That scenario of Oh, I, you know, heard XYZ thing from someone in the
Speaker:care team that this person is using happens a lot or this comes up a lot
Speaker:and can often feel like telephone and knowing what truth is, is hard.
Speaker:And so I would start by sharing frankly what you've learned and then
Speaker:asking for their story or asking their understanding of sort of what's been
Speaker:going on or how things have been going.
Speaker:And then I really have loved Kina's article about shared decision making
Speaker:that references and I think brings up training that we've had around
Speaker:like ask, tell, ask and and really eliciting the patient perspective and
Speaker:continuously getting a sense of where they are when having this conversation.
Speaker:While this may feel disheartening, again, there are many successes that
Speaker:are happening here and that you can sort of approach this conversation
Speaker:and have one that is still warm, welcoming, and open one with, with
Speaker:your patient when trying to negotiate, okay, what, what's best moving forward.
Speaker:I think it's really important for people to hear and not expect that
Speaker:just because someone's in the hospital receiving treatment or on, you know,
Speaker:any sort of maintenance medication.
Speaker:That doesn't mean they're going to stop drug use.
Speaker:There's so many factors that go into that, and it's not black and white,
Speaker:so to expect that everything's just abstinence because someone's being treated
Speaker:for something is really concerning.
Speaker:I feel like this would be an opportunity to really say like, you know, This is
Speaker:why we need a safe supply like across the board for all medications and it would
Speaker:be a great time to advocate for that.
Speaker:I like what you said about having the conversations with the patient and asking.
Speaker:If you don't have a great relationship already built up, people aren't going
Speaker:to tell you anything because for so long, you know, this is drug use
Speaker:is just criminalized and shameful.
Speaker:So we have to lie and hide and hope that people are believing us when we
Speaker:know they probably aren't believing us, but we're not going to tell you
Speaker:the truth because it's shameful.
Speaker:Really being conscious about how you talk to people, that, that is great
Speaker:and I'm glad to see such a shift.
Speaker:Yeah, I totally agree with what both of you have said, and I will say this is
Speaker:actually based on, loosely based on a real case that we saw, and, you know,
Speaker:I think we did exactly that and, you know, we invited the patients for visits,
Speaker:asked permission to talk about things and, you know, describe any triggers you
Speaker:may have had, and, um, In reality, in terms of, like, the clinical management,
Speaker:if helpful, you know, we did check, you know, 2 sets of blood cultures,
Speaker:CBC with diff, CMP, CRP CRPn, and, um, what we did is really just, you know,
Speaker:document the structured conversation, trying to, you know, again, talk about
Speaker:the different antibiotic options.
Speaker:The patients still want the PICC, do they want to do long acting
Speaker:instead, or oral antibiotics, and, you know, just making sure that he
Speaker:had, access to safer use equipments.
Speaker:And also the other thing we did was reaching out to make sure that the
Speaker:respite care center had naloxone on site.
Speaker:Everyone was trained in overdose reversal, which they were, which is great.
Speaker:So, you know, for this particular case, we, you know, wouldn't, wouldn't recommend
Speaker:for him to go to the hospital or pull the PICC line, because, you know, it ended
Speaker:up being his preference that to keep the PICC in and, you know, he under, we kind
Speaker:of went through safer use practices.
Speaker:We know that he has hepatitis C.
Speaker:So, I think it's just probably important to flag that substance use is also not
Speaker:a contraindication to hep C treatment.
Speaker:So we do want to end the hep C epidemic.
Speaker:I think it's really important that we treat people who use drugs and it's
Speaker:probably worth noting too, that there's a bunch of places, Madeline McCurry and
Speaker:colleagues wrote a nice paper on this, but there's a lot of places that have created
Speaker:processes for, you know, discharging people who use drugs with prescriptions
Speaker:for hep C treatment, or at least starting the process for hep C treatment
Speaker:in the hospital or just afterwards.
Speaker:I'm just encouraging ongoing screening as needed afterwards in case of reinfection,
Speaker:which honestly the rates of reinfection thus far is, you know, fairly low,
Speaker:so just a plug for hep C treatment.
Speaker:I'm so glad you brought that up.
Speaker:It's true.
Speaker:I think there was just some, there's an article in the Lancet, I forget
Speaker:which one, that is essentially like, we're not doing, we're not doing
Speaker:so great with hep C elimination.
Speaker:I agree.
Speaker:I love the work that people have been doing, innovating to, to, hep C treatment
Speaker:earlier, but this case is a good example.
Speaker:Like he's four weeks into treatment, could have been four weeks into hep C treatment.
Speaker:Exactly.
Speaker:Well, I am so so grateful that you guys joined Febrile and, you know,
Speaker:helped us think about how to take care of the example scenarios here.
Speaker:I just want to leave the ending here for asking if you have any additional
Speaker:either take home points or highlights that you want to make sure we talk
Speaker:about before we finish up the episode.
Speaker:I just really want to say that I appreciate that harm reduction is being
Speaker:recognized on a much larger scale.
Speaker:I also need to acknowledge that it's not being recognized in
Speaker:appropriate ways across the board.
Speaker:It's really important to continue having conversations and letting
Speaker:people know, like, people who use drugs, they're just people.
Speaker:Like, the who use drugs part doesn't matter.
Speaker:We're all just people.
Speaker:We are no different than anybody else.
Speaker:Yeah, that's it.
Speaker:A take home point from my angle is that these cases, which we see all
Speaker:the time, right, are so common, all included areas in which there's a lot
Speaker:of uncertainty in the medical literature around, you know, How best to choose
Speaker:the right set of oral antibiotics, or oral versus injectable, et cetera.
Speaker:How best to couple infection treatment with substance use disorder
Speaker:treatment, or infection treatment with harm reduction interventions.
Speaker:So we need a ton of more data, and we also need a ton of work that
Speaker:centers the patient voice in all of this, like what do patients want?
Speaker:What works for them?
Speaker:Again, sort of traversing the inpatient outpatient spectrum and, and providing
Speaker:really good models of care that are, that are truly patient centered.
Speaker:And similarly to support that, whether it's grant mechanisms or IDSA and CROI,
Speaker:shout out to those to, to, you know, add, continue to think about focusing
Speaker:on this area will be really helpful.
Speaker:And we've talked a lot about barriers.
Speaker:I think on a hopeful note, I'm really grateful that to work with people who
Speaker:use drugs or folks that have not been in the lines of antibiotic treatment
Speaker:or, or like what we normally do, because I think it is a nice opportunity
Speaker:to push us outside of like, what are our evidence based treatments?
Speaker:Like, what are they based on?
Speaker:And how can we think outside the box and have better fit into people's lives?
Speaker:Yeah.
Speaker:At the end of the day, I think when caring for people, drawing on
Speaker:principles of shared decision making and harm reduction can just really
Speaker:help to optimize patient autonomy.
Speaker:Like you said, Ayesha, just making sure that we include patient voices
Speaker:and really optimize health and safety, which is at the end of the day what
Speaker:we want for all of our patients.
Speaker:Last, I just want to add one piece.
Speaker:I think in talking about harm reduction and especially in medical settings that
Speaker:it's a great opportunity for everybody to really be advocating across the board
Speaker:for access to a safe supply, overdose prevention centers, need based syringe
Speaker:service programs, and change all the policies like We could be leading the
Speaker:way instead of having to be reactionary.
Speaker:I'd love to also just put in a plug for IDSA's member advocacy program, or MAP.
Speaker:You can go on the website and sign up and get involved with a
Speaker:lot of these policy changes, too.
Speaker:Thanks again to our guest stars, Kinna, Ayesha, Chasity for joining Febrile today.
Speaker:You can find their article, Frame Shift, Focusing on harm reduction and
Speaker:shared decision making for people who use drugs, hospitalized with infections
Speaker:linked in the episode information and on the Consult Notes.
Speaker:Don't forget to check out the website, febrilepodcast.
Speaker:com, where you can find our Consult Notes, the library of ID infographics,
Speaker:and a link to our merch store.
Speaker:Febrile is produced with support from the Infectious Diseases
Speaker:Society of America, IDSA.
Speaker:Editing and mixing is provided by Bentley Brown.
Speaker:Please reach out if you have any suggestions for future shows or want
Speaker:to be more involved with Febrile.
Speaker:Thanks for listening, stay safe, and I'll see you next time.
