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Infectious Diseases Physicians’ Perspectives Regarding Injection Drug Use and Related Infections, United States, 2017

Infectious Diseases Physicians’ Perspectives Regarding Injection Drug Use and Related Infections,... Downloaded from https://academic.oup.com/ofid/article-abstract/5/7/ofy132/5034859 by Ed 'DeepDyve' Gillespie user on 16 October 2019 Open Forum Infectious Diseases MAJOR ARTICLE Infectious Diseases Physicians’ Perspectives Regarding Injection Drug Use and Related Infections, United States, 2017 1,7 2 2 4,5 4,5 3,6,7 Alison B. Rapoport, Leah S. Fischer, Scott Santibanez, Susan E. Beekmann, Philip M. Polgreen, and Christopher F. Rowley 1 2 Cambridge Health Alliance, Cambridge, Massachusetts; Division of Preparedness and Emerging Infections, National Center for Emerging and Zoonotic Infectious Diseases, Centers for Disease 3 4 5 Control and Prevention, Atlanta, Georgia; Beth Israel Deaconess Medical Center, Boston, Massachusetts; University of Iowa Carver College of Medicine, Iowa City, Iowa; Emerging Infections 6 7 Network, Iowa City, Iowa; Harvard School of Public Health, Boston, Massachusetts; Harvard Medical School, Boston, Massachusetts Background. In the context of the opioid epidemic, injection drug use (IDU)–related infections are an escalating health issue for infectious diseases (ID) physicians in the United States. Methods. We conducted a mixed methods survey of the Infectious Diseases Society of America’s Emerging Infections Network between February and April 2017 to evaluate perspectives relating to care of persons who inject drugs (PWID). Topics included the frequency of and management strategies for IDU-related infection, the availability of addiction services, and the evolving role of ID physicians in substance use disorder (SUD) management. Results. More than half (53%, n = 672) of 1273 network members participated. Of these, 78% (n = 526) reported treating PWID. Infections frequently encountered included skin and soft tissue (62%, n = 324), bacteremia/fungemia (54%, n = 281), and endocar - ditis (50%, n = 263). In the past year, 79% (n = 416) reported that most IDU-related infections required ≥2 weeks of parenteral anti- biotics; strategies frequently employed for prolonged treatment included completion of the entire course in the inpatient unit (41%, n = 218) or at another supervised facility (35%, n = 182). Only 35% (n = 184) of respondents agreed/strongly agreed that their health system oer ff ed comprehensive SUD management; 46% (n = 242) felt that ID providers should actively manage SUD. Conclusions. e m Th ajority of physicians surveyed treated PWID and reported myriad obstacles to providing care. Public health and health care systems should consider ways to support ID physicians caring for PWID, including (1) guidelines for providing com- plex care, including safe provision of multiweek parenteral antibiotics; (2) improved access to SUD management; and (3) strategies to assist those interested in roles in SUD management. Keywords. bacterial infection; health care surveys; infectious diseases specialty; injection drug use; opioid use disorder. Rates of opioid use and attributable mortality in the United (IDU) has been further highlighted by the increase in new hep- States have risen dramatically in recent years. Provisional data atitis C infections, particularly among those aged 20–29  years from the Centers for Disease Control and Prevention (CDC) [8], and the recent HIV outbreak among persons who inject estimate a 21% increase in national overdose deaths alone drugs (PWID) in Indiana in 2014–2015 [9]. between the 12-month period ending in January 2016 and that In the setting of the national opioid crisis, much remains ending in January 2017 (52 898 deaths vs 64 070 deaths, respec- unknown about infectious diseases (ID) physicians’ experiences tively) [1]. Half a million to 1 million persons inject drugs and perspectives regarding treatment of IDU-related infection and annually in the United States [2, 3], and an estimated 6.6 million opioid use disorder, including buprenorphine prescribing [10, 11]. people have injected drugs during their lifetime [4]. Nationally, In this paper, we describe a mixed methods survey of the Infectious rates of hospitalization and associated costs for serious infec- Diseases Society of America’s (IDSA’s) Emerging Infections tion in persons with opioid use disorders have increased [5], Network (EIN). This survey was designed to solicit member view- notably for endocarditis [6] and skin and soft tissue infection points relating to the care of PWID such as on the prevalence of [7]. Infection arising as a consequence of injection drug use and management strategies for IDU-related infection, the availabil- ity of comprehensive addiction services, and the evolving role of Received 8 March 2018; editorial decision 30 May 2018; accepted 6 June 2018. the infectious diseases physician in the treatment of addiction. Correspondence: A.  B. Rapoport, MD, Cambridge Health Alliance, Division of Infectious Diseases, 1493 Cambridge Street, Cambridge, MA 02139 (arapoport@challiance.org). Open Forum Infectious Diseases METHODS © The Author(s) 2018. Published by Oxford University Press on behalf of Infectious Diseases Society of America. This is an Open Access article distributed under the terms of the Creative Survey Commons Attribution-NonCommercial-NoDerivs licence (http://creativecommons.org/licenses/ by-nc-nd/4.0/), which permits non-commercial reproduction and distribution of the work, in any We disseminated a 14-question multiple choice/open comment medium, provided the original work is not altered or transformed in any way, and that the work survey to members of EIN, a provider-based network of infec- is properly cited. For commercial re-use, please contact journals.permissions@oup.com DOI: 10.1093/ofid/ofy132 tious diseases physicians who are members of the IDSA and ID Practice and Injection Drug Use • OFID • 1 Downloaded from https://academic.oup.com/ofid/article-abstract/5/7/ofy132/5034859 by Ed 'DeepDyve' Gillespie user on 16 October 2019 active in clinical practice (Appendix 1). No incentive for partici- academic, private, and government (Table 1). Years of infectious pation was provided. ID physicians currently in clinical practice diseases practice since fellowship varied among respondents: and EIN staff collaboratively developed the survey with tech- 18% (n = 123) had <5 years of experience, 32% (n = 216) had nical assistance from the CDC. On February 28, 2017, we sent 5–14 years, 18% (n = 123) had 15–24 years, and 32% (n = 213) the confidential survey by e-mail link or by facsimile to 1273 had ≥25  years. Nonrespondents were significantly more likely active EIN members with adult ID practices who had previously to have <25 years of ID experience (P < .0001). responded to 1 or more EIN surveys [12], representing nearly Frequency of Care Provision to PWID 20% of infectious diseases providers currently active in clinical Of 672 respondents, 78% (n =  526) reported treating PWID as practice [13]. part of clinical practice and answered some or all of the remain- Nonresponders received 2 electronic reminders inviting them ing survey questions; the majority of these (79%, n =  416) to participate at approximately 2-week intervals during the reported practicing in both inpatient and outpatient care settings. survey period. The survey remained open until April 9, 2017. Respondents were not asked to identify in which of these settings Primary themes addressed in the survey included the frequency care to PWID was provided. Clinicians in practice for <5  years and characteristics of care provided to PWID, the availability were significantly more likely to treat PWID (89%, n = 109) com- of addiction services, and perspectives on, and participation in, pared with senior clinicians with ≥25 years of experience (67%, n substance abuse and harm reduction interventions. HIV and = 143, P < .0001). Of 526 respondents who treated PWID, 45% (n viral hepatitis management in PWID was considered beyond = 236) reported seeing between 1 and 5 patients per month with the scope of this survey and was not evaluated. Likert-type scale an IDU-related infection, 28% (n =  149) reported seeing 6–15 responses were used for questions that asked about frequency (eg, patients, and 15% (n = 79) reported seeing ≥16 patients. never/rarely/occasionally/frequently), importance, and comfort. Frequencies of IDU-Related Infection We asked open comment questions about opinions/experiences Survey participants were asked to indicate the frequency with related to provision of multiweek parenteral antibiotic courses in which they encountered each of 5 selected IDU-related infec- PWID and helpful strategies for such care. Practice characteris- tions over the last year (2016–2017), including endocarditis, tics of participants, including employment, geographic location, and years of practice, were imported from the EIN database. Table 1. Emerging Infections Network Injection Drug Use and Infectious Analysis Disease Practice Survey—Characteristics of Survey Respondents (n = 672) vs Nonrespondents (n = 601), 2017 We compared geographic and practice characteristics between nonrespondents and respondents to assess nonresponse bias. Respondents, Nonrespondents, Categorical variables were compared using χ or Fisher exact No. (%) No. (%) P Value tests, and differences were considered significant at P  <  .05. Region Quantitative analyses were performed with SAS software (version South 191 (28) 181 (30) 9.4; SAS Institute). For the 2 open response questions, 1 of the Midwest 163 (24) 151 (25) Northeast 159 (24) 122 (20) authors systematically reviewed the comments, deriving codes West 152 (23) 152 (23) inductively and grouping them into content-related categories Canada and Puerto Rico 7 (1) 7 (1) .8168 and higher-order headings. This author then read through the Years experience since ID fellowship text multiple times until all comments that could be coded were <5 123 (18) 122 (20) labeled. Co-authors reviewed the coding system and suggested 5–14 216 (32) 233 (39) 15–24 120 (18) 128 (21) ways to combine or refine categories. We used a qualitative ana- ≥25 213 (32) 118 (20) <.0001 lysis software package (MAXQDA, version 11)  to organize and Employment summarize coded text segments. Comments that were incom- Hospital/clinic 218 (32) 185 (31) plete, unclear, or not relevant to the query were not coded. Private/group practice 189 (28) 171 (28) University/medical 217 (32) 212 (35) school RESULTS VA and military 45 (7) 30 (5) Survey Respondents State government 3 (1) 3 (1) .4486 Primary hospital type More than half (53%, n =  672) of the 1273 active members Community 189 (28) 193 (32) with an adult ID practice participated, a response rate gener- Nonuniversity teaching 164 (24) 145 (24) ally consistent with previous queries [14, 15]. Participants were University 236 (35) 207 (34) drawn from across the United States: 28% (n =  191) from the VA hospital or 49 (7) 33 (5) Department of Defense South, 24% (n =  163) from the Midwest, 24% (n =  159) from City/county 34 (5) 23 (4) .3537 the Northeast, 23% (n =  152) from the West, and 1% (n =  6) from Canada. Employment and practice settings included Abbreviations: ID, infectious diseases; VA, Department of Veterans Affairs. 2 • OFID • Rapoport et al Downloaded from https://academic.oup.com/ofid/article-abstract/5/7/ofy132/5034859 by Ed 'DeepDyve' Gillespie user on 16 October 2019 bone and joint, bacteremia/fungemia, spinal infection (epi- in PWID on a scale of 1–5, 1 being the most important and 5 dural abscess), and skin and soft tissue infection (SSTI). The being the least important. Mean/median scores were calculated to vast majority indicated seeing each of these infections in PWID rank their relative importance among respondents. Of the 5 con- either “occasionally” or “frequently,” with the following cumu- cerns outlined, “ongoing illicit drug use via IV [intravenous] cath- lative percentages: spinal infection 75% (n =  396), bone and eter” was ranked highest (mean, 2.3; median, 2), followed by “drug joint 78% (n =  408), endocarditis 87% (n =  460), bacteremia/ overdose/death resulting from misuse of IV catheter” (mean, 2.6; fungemia 89% (n = 470), and SSTI 90% (n = 473). At least half median, 2), “inadequate follow-up including missed appoint- of all respondents reported “frequently” seeing skin and soft ments and safety monitoring” (mean, 2.6; median, 3), “socioec- tissue infection (61%, n =  322), bacteremia/fungemia (53%, n onomic factors (housing, transportation) contributing to risk of = 278), and endocarditis (50%, n = 261) (Table 2). poor medication adherence and treatment failure” (mean, 3.1; median, 3), and “medicolegal concerns” (mean, 4.2; median, 5). Prolonged Parenteral Therapy: Management Strategies and Areas of Comfort With Injection Practice Assessment; Naloxone Prescribing Concern Frequency Seventy-nine percent (n = 417) of survey participants reported We queried survey participants regarding their degree of com- that from 2016 to 2017 the majority (at least 50%) of IDU- fort “assessing patient injection practices and offering counseling related infections seen required ≥2 weeks of parenteral therapy. regarding safe practices to offset infection risk.” Forty-three We asked respondents to indicate the frequency of 6 manage- percent (n = 225) selected “very comfortable/comfortable,” 27% ment strategies for prolonged parenteral therapy over the last (n =  142) selected “neutral,” 23% (n =  124) selected “uncom- year (Table 3). Common management strategies involved com- fortable/very uncomfortable,” and the remainder 7% (n =  35) pletion of therapy in monitored health care settings, with 41% selected “not sure.” Twenty-two percent (n = 117) had ever pre- indicating “frequently” managing “the entire course on an inpa- scribed naloxone for opioid overdose reversal. tient unit” (n = 217) and 35% indicating “frequently” requesting Availability of Addiction Services; Role of ID Providers “transfer to other supervised facility” (n =  181). Respondents Only 116 (22%) respondents representing 87 discrete insti- largely indicated discomfort with provision of outpatient par- tutions reported that their hospitals provided a dedicated enteral antibiotic therapy (OPAT) to patients with a history of multidisciplinary addictions service. These respondents were IDU, regardless of whether drug injection was active or remote, significantly more likely to “agree/strongly agree” that ID physi- with 65% (n = 344) indicating “never” or “rarely” doing so for cians should actively manage substance use disorders than were patients with clear evidence of sobriety and 70% (n =  368) physicians whose facilities did not provide a dedicated service indicating “never” or “rarely” doing so for patients who were (54% vs 43%, P = 0.03). When queried regarding whether their stable on medication-assisted therapy for opioid use disorder. health system offers comprehensive treatment for substance Alternative antibiotic dosing intervals and routes of adminis- use disorders, only 10% (n =  51) indicated that they “strongly tration for management in PWID were used with varying fre- agree,” compared with 31% (n =  163) who indicated that they quency. The majority indicated prescribing “oral antibiotics with “strongly disagree.” Though nearly half of respondents felt that good oral bioavailability in lieu of parenteral therapy,” with 42% infectious diseases providers should actively manage substance (n = 222) indicating doing so “occasionally” and 13% (n = 67) use disorders (46%, n = 241), only 3% (n = 18) reported being “frequently.” Forty-three percent (n =  224) indicated “never” waivered to prescribe buprenorphine. prescribing “daily or weekly parenteral therapy administered in outpatient setting,” though a cumulative 31% (n =  165) indi- Respondent Opinions/Experiences Relevant to the Management of cated doing so “occasionally” or “frequently” (Table 3). Prolonged Parenteral Therapy for PWID Respondents were asked to rate the relative importance of Ninety respondents provided write-in comments expressing potential concerns pertaining to parenteral therapy management opinions or relating experiences relevant to the management of Table 2. “In the Past Year, How Frequently Have You Seen Each of the Following Complications of IDU?” Responses by 526 Infectious Diseases Physician Members of the Infectious Diseases Society of America Emerging Infections Network, United States, 2017 (Most Frequent Answer in Each Row Appears in Bold) Frequently, No. (%) Occasionally, No. (%) Rarely, No. (%) Never, No. (%) Not Answered, No. Endocarditis 261 (50) 199 (38) 55 (10) 9 (2) 2 Bone and joint 169 (33) 239 (46) 92 (17) 19 (4) 7 Bacteremia/fungemia 278 (54) 192 (37) 44 (8) 6 (1) 6 Spinal infection (epidural abscess) 159 (30) 237 (45) 104 (20) 24 (5) 2 Skin and soft tissue infection 322 (62) 151 (29) 42 (8) 3 (0.6) 8 Abbreviation: IDU, injection drug use. ID Practice and Injection Drug Use • OFID • 3 Downloaded from https://academic.oup.com/ofid/article-abstract/5/7/ofy132/5034859 by Ed 'DeepDyve' Gillespie user on 16 October 2019 Table 3. “In the Past Year, for Infections in PWID Typically Managed With at Least 2 Weeks of Parenteral Therapy, How Frequently Have You Employed the Following Strategies?” Responses by 526 Infectious Diseases Physician Members of the Infectious Diseases Society of America Emerging Infections Network, United States, 2017 (Most Frequent Answer in Each Row Appears in Bold)  Frequently, No. (%) Occasionally, No. (%) Rarely, No. (%) Never, No. (%) Not Answered, No. Transfer to other supervised facility for completion 181 (35) 176 (33) 105 (20) 60 (12) 4 of parenteral therapy Manage entire course of parenteral therapy on in- 217 (41) 161 (31) 104 (20) 40 (8) 4 patient unit Provide OPAT if clear evidence of sobriety 37 (7) 137 (26) 190 (37) 154 (30) 8 Provide OPAT if stable on opioid replacement 23 (4) 123 (24) 166 (32) 202 (40) 12 therapy Prescribe daily or weekly parenteral therapy admin- 45 (9) 120 (23) 128 (25) 224 (43) 9 istered in outpatient infusion setting Prescribe oral antibiotics with good bioavailability in 67 (13) 222 (42) 175 (33) 60 (12) 2 lieu of parenteral therapy Abbreviations: OPAT, outpatient parenteral antibiotic therapy; PWID, people who inject drugs. prolonged parenteral therapy for PWID. Of the 90 responses, underscored a noteworthy challenge: “Substance abuse we thematically coded and organized 82 comments into 1 of the treatment is well beyond the scope of ID trained physician.” following 5 categories: challenging population (n =  55); chal- Eighteen comments indicated a perception that nothing lenging treatment regimens/lack of addiction services (n = 9); works: “None, in absence of a robust health system/hospital alternate treatment strategies (n =  7); policy/legislative/medi- structure providing the necessary auxiliary services to prop- colegal issues (n = 6); and alternate views (n = 5), which were erly treat addiction.” remarks that diverged from the most common themes. Table 4 contains example comments by theme. Alternative Therapeutic Approaches Seven comments addressed oral therapies and single-dose infu- Challenging Patient Population sion antibiotics with dalbavancin and oritavancin. Although 1 Of the 55 comments that identified challenges associated with respondent noted that there are “poor data on oral options,” a treating PWID, almost one-third were general in nature and few respondents mentioned their comfort with the use of oral identified a few underlying issues relevant to the management therapies. One respondent reported using dalbavancin “with of parenteral therapy for PWID. For example, 1 respondent great success,” and another suggested, “Dalvance and orita- identified the “dilemma over whether it is ethical and safe, or at vancin may change this landscape in the near future - and that least appropriate, to send an IDU home with a PICC [periph- would be a fantastic thing.” erally inserted central catheter] line,” whereas another pointed Respondents illustrated policy constraints or barriers at the out that “there are no clear guidelines.... What do you do when a provider, organizational, and state levels: “By setting a local PWID refuses or is ineligible to go to a sub-acute rehab?” standard of care in which we don’t discharge injection drug users on parenteral antibiotics, we make it almost impossible to Barriers to Health Care Access deviate from this standard of care.” In 13 comments that mentioned home health care, all of Some respondents oer ff ed a more positive experience or them indicated that this type of service was not available to opinion. For example, 1 respondent shared the experience that PWID or to those who had a history of injection drug use. “most patients do NOT use their lines to inject drugs – contrary Although a few respondents observed that individuals in to popular opinion.” Another respondent observed that “we this patient population often lack health insurance, having fairly frequently use PICC lines in folk who still inject, without a history of drug use was a substantial obstacle to access- any evidence that doing so leads to more infections than if they ing home health care independent of health care coverage. were injected via another skin site.” Nine respondents identified gaps in the health care system, notably the lack of addiction services. Other treatment chal- Respondents Opinions/Experiences Regarding Helpful Strategies in lenges mentioned in comments included patient relapse Provision of Comprehensive Medical Management to PWID rates, polymicrobial infections, and decisions on surgery for In total, 181 respondents provided write-in comments in infective endocarditis. Network members expressed frustra- response to the question “What strategies have you found par- tion about the lack of resources for the provision of care with ticularly helpful to providing comprehensive medical man- “no concerted effort from either government or individual agement to PWID?” Of the 181 responses, we organized 163 hospital systems to deal with this problem.” One comment comments into 1 of these 5 overarching themes: using inpatient 4 • OFID • Rapoport et al Downloaded from https://academic.oup.com/ofid/article-abstract/5/7/ofy132/5034859 by Ed 'DeepDyve' Gillespie user on 16 October 2019 Table 4. Opinions/Experiences Relevant to the Management of Prolonged Parenteral Therapy—Example Comments by Theme, the Infectious Diseases Society of America Emerging Infections Network, United States, 2017 Challenging Population/General “Dilemma over whether it is ethical and safe, or at least appropriate, to send an IDU home with a PICC line.” “There are no clear guidelines on how to handle this issue. We look for clear evidence of recent sobriety or at least lack of IV drug use.... But what do you do when a PWID refuses or is ineligible to go to a sub-acute rehab.” “This population is extremely difficult to care for and resource intensive. Often we end up keeping them in house for planned duration of therapy and even then patients frequently leave [against medical advice].” “I struggle with this issue. On several occasions, I have felt a patient could be trusted to come to an infusion center daily with PICC to complete therapy, but my colleagues and hospital staff have adamantly refused to discharge with a PICC.” Challenging Population/Catheter Issues “One of my primary concerns is contamination of the line if they are using for drugs, leading to further infections with new organisms, malfunction of the line.” “Most common problem is that patients fail to follow up and contaminate their catheters leading to additional complications.” “Readmissions with superinfections from injecting into lines - often with GNRs or yeast after initial S. aureus infection.” Challenging Population/Barriers to Health Care Access “I would like to prescribe more OPAT to PWID, but in [this] state, none of the home infusion companies will agree to take these patients.” “These patients are nearly impossible to place in NH and the ones that go to NH can still use. I have had them come in follow up to office from NH clearly high saying they can sign out at NH.” “Difficulty getting OPAT nursing services into home. Many times housing is not safe for home nursing visits.” “Many rehab or SAR or NH will not take patients even if on methadone maintenance which complicates things further for those who have negative urine tox screens.” “No home health care facilities will accept pts even if I certify they are in recovery.” Challenging Population/Patient Compliance “Main concern is risk of catheter misuse resulting in new/additional infections in addition to poor compliance, missed appointment and treatment failure for pre- sent infection in patients continuing to inject drugs.” “Compliance in this patient population can be a problem and I sometimes insist on IV therapy to insure observation while on treatment.” Challenging Population/Hospital Payment Issues “Most of our population do not have insurance so they stay in county hospital the entire time.” “I am comfortable w signed consent for outpatient management. However, many have no payor source to allow any alternatives.” “Most patients have no insurance so therefore stay in the hospital.” Challenging Treatment Regimens/Lack of Addiction Services “There is almost no access to drug treatment or opioid replacement therapy in our area.” “Unacceptable rate of relapse due to lack of detox/abstinence programs after hospital discharge.” “We are often stuck with no chronic care options for completion of therapy. Terrible situation.” “With IV access, risk of abuse too high to risk unsupervised approach. Once treated, social services and preventative coordination is key.” Alternate Treatment Strategies “I use IM medications only for outpatient parenteral therapy for PWID. This is faster and I don’t worry about use of an IV line.” “In general even not PWID I am ok with switching to oral relatively early.” “I perceive that I feel much more comfortable than colleagues with oral therapies.” “Using lots of dalbavancin with success.” Policy/Legislative/Medicolegal Issues “Impossible to get them home with PICC because of hospital policies. Reflexively assuming nefariousness with PICC in place in IDUs is the norm, despite evi- dence. Hospital has made dalbavancin and oritavancin outpatient only so can’t start in hospital easily.” “It only takes one case of patient abuse of PICC to change practice to avoid challenging medicolegal situations.” “The state of [X] passed a law in May 2011 shielding MDs and institutions from tort in this situation. Patient has to sign an IVDU/Vascular Access Disclaimer form prior to discharge.” Alternative View “It takes some effort to navigate the social difficulties, but often can be done. In ‘our neck of the woods’ PWID are pretty honest about their habits.” “Great opportunity for use of once weekly intravenous antibiotics.” Abbreviations: GNR, gram negative rods; IDU, injection drug user; IV, intravenous; IVDU, intravenous drug use; NH, nursing home; OPAT, outpatient parenteral antibiotic therapy; PICC, peripherally inserted central catheter; PWID, people who inject drugs; SAR, subacute rehab. and/or outpatient programs (n =  41), linking or referring to either inpatient antibiotics or a combination of inpatient and addiction or mental health services (n =  28), working with a outpatient treatment. Respondents’ comments mentioned a multidisciplinary team (n =  26), provider–patient relationship comprehensive referral center, outpatient coordinated ser- (n = 23), and engaging family/support system (n = 15). Other vices, social workers, and primary care provider involvement categories that emerged included challenges around provision as solutions to the difficulties of managing serious infections of comprehensive medical management to PWID and a gen- in people who use drugs. Other comments identified the use eral lack of helpful strategies (n = 30); we described these chal- of long-acting injectable antibiotics, such as dalbavancin and lenges above. Table 5 contains example comments organized by oritavancin, and 1 respondent advised using oral antibiotics category. when possible. Overall, the most frequently mentioned strategy to pro- e s Th econd and third most common strategies were link- vide comprehensive medical management to PWID involved ing or referring to addiction or mental health services, with 28 ID Practice and Injection Drug Use • OFID • 5 Downloaded from https://academic.oup.com/ofid/article-abstract/5/7/ofy132/5034859 by Ed 'DeepDyve' Gillespie user on 16 October 2019 Table  5. “What Strategies Have You Found Particularly Helpful to Providing Comprehensive Medical Management to PWID?” Example Comments by Theme, the Infectious Diseases Society of America Emerging Infections Network, 2017 Using Inpatient and Outpatient Programs “Best in my experience is when hospital/system can provide dedicated specialist to help patient with substance abuse while inpatient and then link to outpa- tient services.” “Nothing short of prolonged inpatient treatment followed by very attentive outpatient follow up from dedicated addiction specialists.” “Using the severe infection as a tool to help the person address underlying issues, and linking the person with in hospital and out of hospital supports.” Linking or Referring to Addiction Services and Mental Health “All hospitals should have a 12-step program (NA or AA) available for patients and community members in need.” “Our outpatient clinic now has a buprenorphine clinic which is excellent but having greater services inpatient would be of great import.” “Buprenorphine providers affiliated with the medical center with easy follow-up with and multiple spots available.” “Getting them referred to a long-term inpatient setting that includes substance abuse treatment and counseling.” “Assessment via addiction medicine specialist to help determine likelihood of relapsing at discharge.” Working With Multidisciplinar y Team “Working w/ a multidisciplinary team on trying to come up with treatment plans and shared expectations for patients with ongoing IV drug use that are going to be admitted for long term.” “Multi-disciplinary approach so it is not solely my responsibility to decide if patient is safe for home OPAT therapy.” “Creation of a separate multidisciplinary team that focuses on inpatient PWID with infection requiring IV.” “Team approach works best...specialization in addiction medicine...also for the patient getting multiple perspectives and REINFORCEMENT of the message to come clean.” Provider–Patient Relationship “A strong personal relationship and appealing to patient’s self-interest.” “Explicit discussion about concerns regarding active IVDU and effect on plan of care.” “Don’t blame the user. Instead offer support until they become hopeful enough to make a successful quit attempt.” “Taking a nonjudgmental approach to interaction with patients appears to lead to more open communication.” Engaging Family/Support System (Utilize Social/Community Services) “Engage patients support system if available to assist in care and help in bridge to rehab program.” “Early social work and family involvement.” “Social services along with hospital and community services need to join in helping drug addiction.” “Working with community-based partners (i.e. needle exchange and MMT) where people are already receiving services.” “Inpatient order sets for patients with SUDs (includes STI screening, narcan prescribing), staff education/teaching lectures, leadership support, capacity building with community organizations.” “Community/peer navigators, outreach workers.” Challenges “Very limited resources, we usually keep in house for 2–3 weeks then try to D/C on PO. No real rehab available, limited chronic pain management.” “The health system will cover hundreds of thousands of dollars for medical management of infectious complications then not cover any rehab.” “Substance abuse treatment is well beyond the scope of ID trained physician.” “Need more healthcare resources to focus on this issue.” “I see no concerted effort from either government or individual hospital systems to deal with this problem.” Abbreviations: AA, Alcoholics Anonymous; D/C, discharge; ID, infectious diseases; IV, intravenous; IVDU, intravenous drug use; MMT, methadone maintenance treatment; NA, Narcotics Anonymous; PO, per oral; OPAT, outpatient parenteral antibiotic therapy; PWID, people who inject drugs; STI, sexually transmitted infection; SUD, substance use disorder. comments, and working with a multidisciplinary team, with 26 Extending beyond the provider–patient relationship, 15 comments. Respondents noted that comprehensive medical man- respondents identified engaging patients’ families or support agement of PWID “works best when combined with some sort systems and using social or community services. In general, of addiction recovery” and a “multidisciplinary approach to care comments suggested that family/support system engagement [is the] only chance of making a difference.” Comments included was helpful to assistance with care, notably getting patients into inpatient drug rehabilitation and linkage to addiction programs outpatient programs or drug rehabilitation programs. With at hospital discharge. A  few respondents specifically identified regard to utilizing social/community services, respondents’ buprenorphine and methadone treatments for opioid use dis- comments reiterated the need for medical management focused order. Other strategies cited included comanagement with syringe on PWID to go beyond treating infections: “Social services exchange programs/substance abuse counseling and targeting along with hospital and community services need to join in social determinants of health with each visit to the health care helping drug addiction.” system. DISCUSSION Twenty-three respondents commented on the provider– patient relationship. Several survey participants reported hav- In this national sample of infectious diseases clinicians, the ing open dialogue with patients about risks. With 6 unique majority of survey participants reported providing care to instances of the term “nonjudgmental,” other comments catego- PWID, suggesting that treatment of serious IDU-related infec- rized within this theme contained words that included “trust,” tion is a common feature of today’s infectious diseases practice “support,” “understanding,” and “patience.” in the United States. For a subset of providers, provision of 6 • OFID • Rapoport et al Downloaded from https://academic.oup.com/ofid/article-abstract/5/7/ofy132/5034859 by Ed 'DeepDyve' Gillespie user on 16 October 2019 care to PWID represents a substantial component of clinical Second, we relied on self-reports and responses, which may be practice. In both multiple choice and open text responses, subject to recall bias. Lastly, given that nonrespondents were physicians highlighted the often complex, resource-intensive significantly more likely than respondents to have less than nature of providing care to PWID, owing to infection sever- 25  years of ID experience, the findings of the survey may not ity (frequently requiring >2 weeks of parenteral antibiotic represent the experience of younger respondents. This is par - treatment) and structural barriers to conventional manage- ticularly noteworthy, as clinicians in practice for <5 years were ment (psychosocial complexity and lack of insurance, among significantly more likely to treat PWID (89%) compared with others). senior clinicians with ≥25 years of experience (67%, P < .0001). Our results demonstrate an overall lack of resources for ID er Th efore, follow-up queries targeting the experience of infec- physicians treating PWID. For example, only a small number tious diseases providers in earlier stages of practice may better of ID providers queried (10%, n =  51) strongly agreed that reflect the full range of experiences and challenges relevant to their care setting provided comprehensive substance use treat- caring for PWID. ment, highlighting that the majority of providers treat complex In the setting of the escalating opioid crisis, complex care infection in PWID who lack access to treatment for underlying requirements for PWID will persist, highlighting the need for opioid use disorders. Respondents expressed diverse opinions guidelines and further research to identify best practices for regarding the potential role for ID providers in the management management. Expansion of ID providers’ clinical purview to of addiction, and acquisition of a federal waiver to prescribe integrate concurrent addiction treatment and harm reduction buprenorphine was rare among respondents, commensurate represents 1 novel element that merits further consideration. with national data reporting that approximately 4% of practic- Acknowledgments ing physicians have waiver certification [16]. e a Th uthors thank Brian Edlin, Robert Pinner, and Toby Merlin for their Given the challenges facing ID physicians caring for an review of and helpful input on the manuscript.  increasing number of PWID, our results suggest that public Financial support. This publication was supported by Cooperative health and health care officials should consider ways to enhance Agreement Number 1 U50 CK000477, funded by the Centers for Disease Control and Prevention. Its contents are solely the responsibility of the the evolving role of ID physicians in the care of PWID. The authors and do not necessarily represent the official views of the Centers for IDSA could consider the development of guidelines, a research Disease Control and Prevention or the Department of Health and Human agenda to identify knowledge gaps, and other resources to Services. Potential conifl cts of interest. All authors: no reported conflicts of address the complex care of PWID, including safe provision of interest. All authors have submitted the ICMJE Form for Disclosure of multiweek parenteral therapy. Hospitals and health care systems Potential Conflicts of Interest. Conflicts that the editors consider relevant to can consider ways to improve comprehensive substance use dis- the content of the manuscript have been disclosed. order treatment, including use of multidisciplinary teams, link- age to addiction or mental health services, syringe exchange References 1. Centers for Disease Control and Prevention. Provisional counts of drug over- programs, and family/support systems. dose deaths as of august 6, 2017. Available at: http://www.cdc.gov/nchs/data/ Some ID physicians expressed interest in taking an active health_policy/monthly-drug-overdose-death-estimates.pdf. Accessed 12 role in the management of SUD. To this end, training in addic- October 2017. 2. Centers for Disease Control and Prevention. Today’s heroin epidemic. 2015. tion and the care of people who use drugs should be avail- Available at: http://www.cdc.gov/vitalsigns/heroin/index.html. Accessed 13 June able to all ID physicians. Under the federal Drug Addiction 3. Centers for Disease Control and Prevention. Heroin overdose data. 2017. Treatment Act of 2000, physicians who register with the Drug Available at: https://www.cdc.gov/drugoverdose/data/heroin.html. Accessed 12 Enforcement Administration, regardless of their subspecialty, October 2017. 4. Lansky A, Finlayson T, Johnson C, et al. Estimating the number of persons who can receive a waiver to prescribe buprenorphine for opioid use inject drugs in the United States by meta-analysis to calculate national rates of disorder treatment aer un ft dergoing 8 hours of training [17]. HIV and hepatitis C virus infections. PLoS One 2014; 9:e97596. 5. Ronan MV, Herzig SJ. Hospitalizations related to opioid abuse/dependence and For those with particular interest, dual training in addiction associated serious infections increased sharply, 2002–12. Health Aff (Millwood) medicine may be of value. In March 2016, the American Board 2016; 35:832–7. of Medical Specialties announced addiction medicine as a sub- 6. Wurcel AG, Anderson JE, Chui KK, et  al. Increasing infectious endocarditis admissions among young people who inject drugs. Open Forum Infect Dis 2016; specialty under the American Board of Preventive Medicine. 3:ofw157. During the next 5 years, physicians who have a primary ABMS 7. Ciccarone D, Unick GJ, Cohen JK, et al. Nationwide increase in hospitalizations for heroin-related soft tissue infections: associations with structural market con- board certification may apply to take the exam to become or ditions. Drug Alcohol Depend 2016; 163:126–33. continue to be an addiction medicine specialist. Aer t ft he 5-year 8. Centers for Disease Control and Prevention. New hepatitis C infections nearly tri- pled over five years. Available at: https://www.cdc.gov/nchhstp/newsroom/2017/ period ends, a 1-year fellowship will be required to become an Hepatitis-Surveillance-Press-Release.html. Accessed 18 October 2017. addiction medicine specialist [18]. 9. Peters PJ, Pontones P, Hoover KW, et al. HIV infection linked to injection use of oxymorphone in Indiana, 2014–2015. N Engl J Med 2016; 375:229–39. Our study has several notable limitations. EIN is a conveni- 10. Sullivan LE, Fiellin DA. Buprenorphine: its role in preventing HIV transmission ence sample of physicians, so the opinions of respondents may and improving the care of HIV-infected patients with opioid dependence. Clin not be generalizable to other infectious diseases physicians. Infect Dis 2005; 41:891–6. ID Practice and Injection Drug Use • OFID • 7 Downloaded from https://academic.oup.com/ofid/article-abstract/5/7/ofy132/5034859 by Ed 'DeepDyve' Gillespie user on 16 October 2019 11. Buehrle DJ, Shields RK, Shah N, et al. Risk factors associated with outpatient par- 15. Chastain CA, Beekmann SE, Wallender EK, et al. Hepatitis C management and enteral antibiotic therapy program failure among intravenous drug users. Open the infectious diseases physician: a survey of current and anticipated practice pat- Forum Infect Dis 2017; 4:ofx102. terns. Clin Infect Dis 2015; 61:792–4. 12. Pillai SK, Beekmann SE, Santibanez S, Polgreen PM. The Infectious Diseases 16. Rapoport AB, Rowley CF. Stretching the scope - becoming frontline addic- Society of America Emerging Infections Network: bridging the gap between tion-medicine providers. N Engl J Med 2017; 377:705–7. clinical infectious diseases and public health. Clin Infect Dis 2014; 58:991–6. 17. Substance Abuse and Mental Health Services Administration. Buprenorphine 13. Association of American Medical Colleges. 2016 physician specialty data report. waiver management. Available at: https://www.samhsagov/medication-as- Available at: https://www.aamc.org/data/workforce/reorts/458480/1-1-chart. sisted treatment/buprenorphine-waiver-management. Accessed 8 January html. Accessed 16 November 2017. 2018. 14. Krakower DS, Beekmann SE, Polgreen PM, Mayer KH. Diffusion of newer HIV 18. American Society of Addiction Medicine. Addiction medicine (ADM) official prevention innovations: variable practices of frontline infectious diseases physi- ABMS subspecialty. Available at: https://www.asam.org/education/certifica- cians. Clin Infect Dis 2016; 62:99–105. tion-and-moc. Accessed 16 September 2017. 8 • OFID • Rapoport et al Downloaded from https://academic.oup.com/ofid/article-abstract/5/7/ofy132/5034859 by Ed 'DeepDyve' Gillespie user on 16 October 2019 ID Practice and Injection Drug Use • OFID • 9 Downloaded from https://academic.oup.com/ofid/article-abstract/5/7/ofy132/5034859 by Ed 'DeepDyve' Gillespie user on 16 October 2019 10 • OFID • Rapoport et al http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Open Forum Infectious Diseases Oxford University Press

Infectious Diseases Physicians’ Perspectives Regarding Injection Drug Use and Related Infections, United States, 2017

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Downloaded from https://academic.oup.com/ofid/article-abstract/5/7/ofy132/5034859 by Ed 'DeepDyve' Gillespie user on 16 October 2019 Open Forum Infectious Diseases MAJOR ARTICLE Infectious Diseases Physicians’ Perspectives Regarding Injection Drug Use and Related Infections, United States, 2017 1,7 2 2 4,5 4,5 3,6,7 Alison B. Rapoport, Leah S. Fischer, Scott Santibanez, Susan E. Beekmann, Philip M. Polgreen, and Christopher F. Rowley 1 2 Cambridge Health Alliance, Cambridge, Massachusetts; Division of Preparedness and Emerging Infections, National Center for Emerging and Zoonotic Infectious Diseases, Centers for Disease 3 4 5 Control and Prevention, Atlanta, Georgia; Beth Israel Deaconess Medical Center, Boston, Massachusetts; University of Iowa Carver College of Medicine, Iowa City, Iowa; Emerging Infections 6 7 Network, Iowa City, Iowa; Harvard School of Public Health, Boston, Massachusetts; Harvard Medical School, Boston, Massachusetts Background. In the context of the opioid epidemic, injection drug use (IDU)–related infections are an escalating health issue for infectious diseases (ID) physicians in the United States. Methods. We conducted a mixed methods survey of the Infectious Diseases Society of America’s Emerging Infections Network between February and April 2017 to evaluate perspectives relating to care of persons who inject drugs (PWID). Topics included the frequency of and management strategies for IDU-related infection, the availability of addiction services, and the evolving role of ID physicians in substance use disorder (SUD) management. Results. More than half (53%, n = 672) of 1273 network members participated. Of these, 78% (n = 526) reported treating PWID. Infections frequently encountered included skin and soft tissue (62%, n = 324), bacteremia/fungemia (54%, n = 281), and endocar - ditis (50%, n = 263). In the past year, 79% (n = 416) reported that most IDU-related infections required ≥2 weeks of parenteral anti- biotics; strategies frequently employed for prolonged treatment included completion of the entire course in the inpatient unit (41%, n = 218) or at another supervised facility (35%, n = 182). Only 35% (n = 184) of respondents agreed/strongly agreed that their health system oer ff ed comprehensive SUD management; 46% (n = 242) felt that ID providers should actively manage SUD. Conclusions. e m Th ajority of physicians surveyed treated PWID and reported myriad obstacles to providing care. Public health and health care systems should consider ways to support ID physicians caring for PWID, including (1) guidelines for providing com- plex care, including safe provision of multiweek parenteral antibiotics; (2) improved access to SUD management; and (3) strategies to assist those interested in roles in SUD management. Keywords. bacterial infection; health care surveys; infectious diseases specialty; injection drug use; opioid use disorder. Rates of opioid use and attributable mortality in the United (IDU) has been further highlighted by the increase in new hep- States have risen dramatically in recent years. Provisional data atitis C infections, particularly among those aged 20–29  years from the Centers for Disease Control and Prevention (CDC) [8], and the recent HIV outbreak among persons who inject estimate a 21% increase in national overdose deaths alone drugs (PWID) in Indiana in 2014–2015 [9]. between the 12-month period ending in January 2016 and that In the setting of the national opioid crisis, much remains ending in January 2017 (52 898 deaths vs 64 070 deaths, respec- unknown about infectious diseases (ID) physicians’ experiences tively) [1]. Half a million to 1 million persons inject drugs and perspectives regarding treatment of IDU-related infection and annually in the United States [2, 3], and an estimated 6.6 million opioid use disorder, including buprenorphine prescribing [10, 11]. people have injected drugs during their lifetime [4]. Nationally, In this paper, we describe a mixed methods survey of the Infectious rates of hospitalization and associated costs for serious infec- Diseases Society of America’s (IDSA’s) Emerging Infections tion in persons with opioid use disorders have increased [5], Network (EIN). This survey was designed to solicit member view- notably for endocarditis [6] and skin and soft tissue infection points relating to the care of PWID such as on the prevalence of [7]. Infection arising as a consequence of injection drug use and management strategies for IDU-related infection, the availabil- ity of comprehensive addiction services, and the evolving role of Received 8 March 2018; editorial decision 30 May 2018; accepted 6 June 2018. the infectious diseases physician in the treatment of addiction. Correspondence: A.  B. Rapoport, MD, Cambridge Health Alliance, Division of Infectious Diseases, 1493 Cambridge Street, Cambridge, MA 02139 (arapoport@challiance.org). Open Forum Infectious Diseases METHODS © The Author(s) 2018. Published by Oxford University Press on behalf of Infectious Diseases Society of America. This is an Open Access article distributed under the terms of the Creative Survey Commons Attribution-NonCommercial-NoDerivs licence (http://creativecommons.org/licenses/ by-nc-nd/4.0/), which permits non-commercial reproduction and distribution of the work, in any We disseminated a 14-question multiple choice/open comment medium, provided the original work is not altered or transformed in any way, and that the work survey to members of EIN, a provider-based network of infec- is properly cited. For commercial re-use, please contact journals.permissions@oup.com DOI: 10.1093/ofid/ofy132 tious diseases physicians who are members of the IDSA and ID Practice and Injection Drug Use • OFID • 1 Downloaded from https://academic.oup.com/ofid/article-abstract/5/7/ofy132/5034859 by Ed 'DeepDyve' Gillespie user on 16 October 2019 active in clinical practice (Appendix 1). No incentive for partici- academic, private, and government (Table 1). Years of infectious pation was provided. ID physicians currently in clinical practice diseases practice since fellowship varied among respondents: and EIN staff collaboratively developed the survey with tech- 18% (n = 123) had <5 years of experience, 32% (n = 216) had nical assistance from the CDC. On February 28, 2017, we sent 5–14 years, 18% (n = 123) had 15–24 years, and 32% (n = 213) the confidential survey by e-mail link or by facsimile to 1273 had ≥25  years. Nonrespondents were significantly more likely active EIN members with adult ID practices who had previously to have <25 years of ID experience (P < .0001). responded to 1 or more EIN surveys [12], representing nearly Frequency of Care Provision to PWID 20% of infectious diseases providers currently active in clinical Of 672 respondents, 78% (n =  526) reported treating PWID as practice [13]. part of clinical practice and answered some or all of the remain- Nonresponders received 2 electronic reminders inviting them ing survey questions; the majority of these (79%, n =  416) to participate at approximately 2-week intervals during the reported practicing in both inpatient and outpatient care settings. survey period. The survey remained open until April 9, 2017. Respondents were not asked to identify in which of these settings Primary themes addressed in the survey included the frequency care to PWID was provided. Clinicians in practice for <5  years and characteristics of care provided to PWID, the availability were significantly more likely to treat PWID (89%, n = 109) com- of addiction services, and perspectives on, and participation in, pared with senior clinicians with ≥25 years of experience (67%, n substance abuse and harm reduction interventions. HIV and = 143, P < .0001). Of 526 respondents who treated PWID, 45% (n viral hepatitis management in PWID was considered beyond = 236) reported seeing between 1 and 5 patients per month with the scope of this survey and was not evaluated. Likert-type scale an IDU-related infection, 28% (n =  149) reported seeing 6–15 responses were used for questions that asked about frequency (eg, patients, and 15% (n = 79) reported seeing ≥16 patients. never/rarely/occasionally/frequently), importance, and comfort. Frequencies of IDU-Related Infection We asked open comment questions about opinions/experiences Survey participants were asked to indicate the frequency with related to provision of multiweek parenteral antibiotic courses in which they encountered each of 5 selected IDU-related infec- PWID and helpful strategies for such care. Practice characteris- tions over the last year (2016–2017), including endocarditis, tics of participants, including employment, geographic location, and years of practice, were imported from the EIN database. Table 1. Emerging Infections Network Injection Drug Use and Infectious Analysis Disease Practice Survey—Characteristics of Survey Respondents (n = 672) vs Nonrespondents (n = 601), 2017 We compared geographic and practice characteristics between nonrespondents and respondents to assess nonresponse bias. Respondents, Nonrespondents, Categorical variables were compared using χ or Fisher exact No. (%) No. (%) P Value tests, and differences were considered significant at P  <  .05. Region Quantitative analyses were performed with SAS software (version South 191 (28) 181 (30) 9.4; SAS Institute). For the 2 open response questions, 1 of the Midwest 163 (24) 151 (25) Northeast 159 (24) 122 (20) authors systematically reviewed the comments, deriving codes West 152 (23) 152 (23) inductively and grouping them into content-related categories Canada and Puerto Rico 7 (1) 7 (1) .8168 and higher-order headings. This author then read through the Years experience since ID fellowship text multiple times until all comments that could be coded were <5 123 (18) 122 (20) labeled. Co-authors reviewed the coding system and suggested 5–14 216 (32) 233 (39) 15–24 120 (18) 128 (21) ways to combine or refine categories. We used a qualitative ana- ≥25 213 (32) 118 (20) <.0001 lysis software package (MAXQDA, version 11)  to organize and Employment summarize coded text segments. Comments that were incom- Hospital/clinic 218 (32) 185 (31) plete, unclear, or not relevant to the query were not coded. Private/group practice 189 (28) 171 (28) University/medical 217 (32) 212 (35) school RESULTS VA and military 45 (7) 30 (5) Survey Respondents State government 3 (1) 3 (1) .4486 Primary hospital type More than half (53%, n =  672) of the 1273 active members Community 189 (28) 193 (32) with an adult ID practice participated, a response rate gener- Nonuniversity teaching 164 (24) 145 (24) ally consistent with previous queries [14, 15]. Participants were University 236 (35) 207 (34) drawn from across the United States: 28% (n =  191) from the VA hospital or 49 (7) 33 (5) Department of Defense South, 24% (n =  163) from the Midwest, 24% (n =  159) from City/county 34 (5) 23 (4) .3537 the Northeast, 23% (n =  152) from the West, and 1% (n =  6) from Canada. Employment and practice settings included Abbreviations: ID, infectious diseases; VA, Department of Veterans Affairs. 2 • OFID • Rapoport et al Downloaded from https://academic.oup.com/ofid/article-abstract/5/7/ofy132/5034859 by Ed 'DeepDyve' Gillespie user on 16 October 2019 bone and joint, bacteremia/fungemia, spinal infection (epi- in PWID on a scale of 1–5, 1 being the most important and 5 dural abscess), and skin and soft tissue infection (SSTI). The being the least important. Mean/median scores were calculated to vast majority indicated seeing each of these infections in PWID rank their relative importance among respondents. Of the 5 con- either “occasionally” or “frequently,” with the following cumu- cerns outlined, “ongoing illicit drug use via IV [intravenous] cath- lative percentages: spinal infection 75% (n =  396), bone and eter” was ranked highest (mean, 2.3; median, 2), followed by “drug joint 78% (n =  408), endocarditis 87% (n =  460), bacteremia/ overdose/death resulting from misuse of IV catheter” (mean, 2.6; fungemia 89% (n = 470), and SSTI 90% (n = 473). At least half median, 2), “inadequate follow-up including missed appoint- of all respondents reported “frequently” seeing skin and soft ments and safety monitoring” (mean, 2.6; median, 3), “socioec- tissue infection (61%, n =  322), bacteremia/fungemia (53%, n onomic factors (housing, transportation) contributing to risk of = 278), and endocarditis (50%, n = 261) (Table 2). poor medication adherence and treatment failure” (mean, 3.1; median, 3), and “medicolegal concerns” (mean, 4.2; median, 5). Prolonged Parenteral Therapy: Management Strategies and Areas of Comfort With Injection Practice Assessment; Naloxone Prescribing Concern Frequency Seventy-nine percent (n = 417) of survey participants reported We queried survey participants regarding their degree of com- that from 2016 to 2017 the majority (at least 50%) of IDU- fort “assessing patient injection practices and offering counseling related infections seen required ≥2 weeks of parenteral therapy. regarding safe practices to offset infection risk.” Forty-three We asked respondents to indicate the frequency of 6 manage- percent (n = 225) selected “very comfortable/comfortable,” 27% ment strategies for prolonged parenteral therapy over the last (n =  142) selected “neutral,” 23% (n =  124) selected “uncom- year (Table 3). Common management strategies involved com- fortable/very uncomfortable,” and the remainder 7% (n =  35) pletion of therapy in monitored health care settings, with 41% selected “not sure.” Twenty-two percent (n = 117) had ever pre- indicating “frequently” managing “the entire course on an inpa- scribed naloxone for opioid overdose reversal. tient unit” (n = 217) and 35% indicating “frequently” requesting Availability of Addiction Services; Role of ID Providers “transfer to other supervised facility” (n =  181). Respondents Only 116 (22%) respondents representing 87 discrete insti- largely indicated discomfort with provision of outpatient par- tutions reported that their hospitals provided a dedicated enteral antibiotic therapy (OPAT) to patients with a history of multidisciplinary addictions service. These respondents were IDU, regardless of whether drug injection was active or remote, significantly more likely to “agree/strongly agree” that ID physi- with 65% (n = 344) indicating “never” or “rarely” doing so for cians should actively manage substance use disorders than were patients with clear evidence of sobriety and 70% (n =  368) physicians whose facilities did not provide a dedicated service indicating “never” or “rarely” doing so for patients who were (54% vs 43%, P = 0.03). When queried regarding whether their stable on medication-assisted therapy for opioid use disorder. health system offers comprehensive treatment for substance Alternative antibiotic dosing intervals and routes of adminis- use disorders, only 10% (n =  51) indicated that they “strongly tration for management in PWID were used with varying fre- agree,” compared with 31% (n =  163) who indicated that they quency. The majority indicated prescribing “oral antibiotics with “strongly disagree.” Though nearly half of respondents felt that good oral bioavailability in lieu of parenteral therapy,” with 42% infectious diseases providers should actively manage substance (n = 222) indicating doing so “occasionally” and 13% (n = 67) use disorders (46%, n = 241), only 3% (n = 18) reported being “frequently.” Forty-three percent (n =  224) indicated “never” waivered to prescribe buprenorphine. prescribing “daily or weekly parenteral therapy administered in outpatient setting,” though a cumulative 31% (n =  165) indi- Respondent Opinions/Experiences Relevant to the Management of cated doing so “occasionally” or “frequently” (Table 3). Prolonged Parenteral Therapy for PWID Respondents were asked to rate the relative importance of Ninety respondents provided write-in comments expressing potential concerns pertaining to parenteral therapy management opinions or relating experiences relevant to the management of Table 2. “In the Past Year, How Frequently Have You Seen Each of the Following Complications of IDU?” Responses by 526 Infectious Diseases Physician Members of the Infectious Diseases Society of America Emerging Infections Network, United States, 2017 (Most Frequent Answer in Each Row Appears in Bold) Frequently, No. (%) Occasionally, No. (%) Rarely, No. (%) Never, No. (%) Not Answered, No. Endocarditis 261 (50) 199 (38) 55 (10) 9 (2) 2 Bone and joint 169 (33) 239 (46) 92 (17) 19 (4) 7 Bacteremia/fungemia 278 (54) 192 (37) 44 (8) 6 (1) 6 Spinal infection (epidural abscess) 159 (30) 237 (45) 104 (20) 24 (5) 2 Skin and soft tissue infection 322 (62) 151 (29) 42 (8) 3 (0.6) 8 Abbreviation: IDU, injection drug use. ID Practice and Injection Drug Use • OFID • 3 Downloaded from https://academic.oup.com/ofid/article-abstract/5/7/ofy132/5034859 by Ed 'DeepDyve' Gillespie user on 16 October 2019 Table 3. “In the Past Year, for Infections in PWID Typically Managed With at Least 2 Weeks of Parenteral Therapy, How Frequently Have You Employed the Following Strategies?” Responses by 526 Infectious Diseases Physician Members of the Infectious Diseases Society of America Emerging Infections Network, United States, 2017 (Most Frequent Answer in Each Row Appears in Bold)  Frequently, No. (%) Occasionally, No. (%) Rarely, No. (%) Never, No. (%) Not Answered, No. Transfer to other supervised facility for completion 181 (35) 176 (33) 105 (20) 60 (12) 4 of parenteral therapy Manage entire course of parenteral therapy on in- 217 (41) 161 (31) 104 (20) 40 (8) 4 patient unit Provide OPAT if clear evidence of sobriety 37 (7) 137 (26) 190 (37) 154 (30) 8 Provide OPAT if stable on opioid replacement 23 (4) 123 (24) 166 (32) 202 (40) 12 therapy Prescribe daily or weekly parenteral therapy admin- 45 (9) 120 (23) 128 (25) 224 (43) 9 istered in outpatient infusion setting Prescribe oral antibiotics with good bioavailability in 67 (13) 222 (42) 175 (33) 60 (12) 2 lieu of parenteral therapy Abbreviations: OPAT, outpatient parenteral antibiotic therapy; PWID, people who inject drugs. prolonged parenteral therapy for PWID. Of the 90 responses, underscored a noteworthy challenge: “Substance abuse we thematically coded and organized 82 comments into 1 of the treatment is well beyond the scope of ID trained physician.” following 5 categories: challenging population (n =  55); chal- Eighteen comments indicated a perception that nothing lenging treatment regimens/lack of addiction services (n = 9); works: “None, in absence of a robust health system/hospital alternate treatment strategies (n =  7); policy/legislative/medi- structure providing the necessary auxiliary services to prop- colegal issues (n = 6); and alternate views (n = 5), which were erly treat addiction.” remarks that diverged from the most common themes. Table 4 contains example comments by theme. Alternative Therapeutic Approaches Seven comments addressed oral therapies and single-dose infu- Challenging Patient Population sion antibiotics with dalbavancin and oritavancin. Although 1 Of the 55 comments that identified challenges associated with respondent noted that there are “poor data on oral options,” a treating PWID, almost one-third were general in nature and few respondents mentioned their comfort with the use of oral identified a few underlying issues relevant to the management therapies. One respondent reported using dalbavancin “with of parenteral therapy for PWID. For example, 1 respondent great success,” and another suggested, “Dalvance and orita- identified the “dilemma over whether it is ethical and safe, or at vancin may change this landscape in the near future - and that least appropriate, to send an IDU home with a PICC [periph- would be a fantastic thing.” erally inserted central catheter] line,” whereas another pointed Respondents illustrated policy constraints or barriers at the out that “there are no clear guidelines.... What do you do when a provider, organizational, and state levels: “By setting a local PWID refuses or is ineligible to go to a sub-acute rehab?” standard of care in which we don’t discharge injection drug users on parenteral antibiotics, we make it almost impossible to Barriers to Health Care Access deviate from this standard of care.” In 13 comments that mentioned home health care, all of Some respondents oer ff ed a more positive experience or them indicated that this type of service was not available to opinion. For example, 1 respondent shared the experience that PWID or to those who had a history of injection drug use. “most patients do NOT use their lines to inject drugs – contrary Although a few respondents observed that individuals in to popular opinion.” Another respondent observed that “we this patient population often lack health insurance, having fairly frequently use PICC lines in folk who still inject, without a history of drug use was a substantial obstacle to access- any evidence that doing so leads to more infections than if they ing home health care independent of health care coverage. were injected via another skin site.” Nine respondents identified gaps in the health care system, notably the lack of addiction services. Other treatment chal- Respondents Opinions/Experiences Regarding Helpful Strategies in lenges mentioned in comments included patient relapse Provision of Comprehensive Medical Management to PWID rates, polymicrobial infections, and decisions on surgery for In total, 181 respondents provided write-in comments in infective endocarditis. Network members expressed frustra- response to the question “What strategies have you found par- tion about the lack of resources for the provision of care with ticularly helpful to providing comprehensive medical man- “no concerted effort from either government or individual agement to PWID?” Of the 181 responses, we organized 163 hospital systems to deal with this problem.” One comment comments into 1 of these 5 overarching themes: using inpatient 4 • OFID • Rapoport et al Downloaded from https://academic.oup.com/ofid/article-abstract/5/7/ofy132/5034859 by Ed 'DeepDyve' Gillespie user on 16 October 2019 Table 4. Opinions/Experiences Relevant to the Management of Prolonged Parenteral Therapy—Example Comments by Theme, the Infectious Diseases Society of America Emerging Infections Network, United States, 2017 Challenging Population/General “Dilemma over whether it is ethical and safe, or at least appropriate, to send an IDU home with a PICC line.” “There are no clear guidelines on how to handle this issue. We look for clear evidence of recent sobriety or at least lack of IV drug use.... But what do you do when a PWID refuses or is ineligible to go to a sub-acute rehab.” “This population is extremely difficult to care for and resource intensive. Often we end up keeping them in house for planned duration of therapy and even then patients frequently leave [against medical advice].” “I struggle with this issue. On several occasions, I have felt a patient could be trusted to come to an infusion center daily with PICC to complete therapy, but my colleagues and hospital staff have adamantly refused to discharge with a PICC.” Challenging Population/Catheter Issues “One of my primary concerns is contamination of the line if they are using for drugs, leading to further infections with new organisms, malfunction of the line.” “Most common problem is that patients fail to follow up and contaminate their catheters leading to additional complications.” “Readmissions with superinfections from injecting into lines - often with GNRs or yeast after initial S. aureus infection.” Challenging Population/Barriers to Health Care Access “I would like to prescribe more OPAT to PWID, but in [this] state, none of the home infusion companies will agree to take these patients.” “These patients are nearly impossible to place in NH and the ones that go to NH can still use. I have had them come in follow up to office from NH clearly high saying they can sign out at NH.” “Difficulty getting OPAT nursing services into home. Many times housing is not safe for home nursing visits.” “Many rehab or SAR or NH will not take patients even if on methadone maintenance which complicates things further for those who have negative urine tox screens.” “No home health care facilities will accept pts even if I certify they are in recovery.” Challenging Population/Patient Compliance “Main concern is risk of catheter misuse resulting in new/additional infections in addition to poor compliance, missed appointment and treatment failure for pre- sent infection in patients continuing to inject drugs.” “Compliance in this patient population can be a problem and I sometimes insist on IV therapy to insure observation while on treatment.” Challenging Population/Hospital Payment Issues “Most of our population do not have insurance so they stay in county hospital the entire time.” “I am comfortable w signed consent for outpatient management. However, many have no payor source to allow any alternatives.” “Most patients have no insurance so therefore stay in the hospital.” Challenging Treatment Regimens/Lack of Addiction Services “There is almost no access to drug treatment or opioid replacement therapy in our area.” “Unacceptable rate of relapse due to lack of detox/abstinence programs after hospital discharge.” “We are often stuck with no chronic care options for completion of therapy. Terrible situation.” “With IV access, risk of abuse too high to risk unsupervised approach. Once treated, social services and preventative coordination is key.” Alternate Treatment Strategies “I use IM medications only for outpatient parenteral therapy for PWID. This is faster and I don’t worry about use of an IV line.” “In general even not PWID I am ok with switching to oral relatively early.” “I perceive that I feel much more comfortable than colleagues with oral therapies.” “Using lots of dalbavancin with success.” Policy/Legislative/Medicolegal Issues “Impossible to get them home with PICC because of hospital policies. Reflexively assuming nefariousness with PICC in place in IDUs is the norm, despite evi- dence. Hospital has made dalbavancin and oritavancin outpatient only so can’t start in hospital easily.” “It only takes one case of patient abuse of PICC to change practice to avoid challenging medicolegal situations.” “The state of [X] passed a law in May 2011 shielding MDs and institutions from tort in this situation. Patient has to sign an IVDU/Vascular Access Disclaimer form prior to discharge.” Alternative View “It takes some effort to navigate the social difficulties, but often can be done. In ‘our neck of the woods’ PWID are pretty honest about their habits.” “Great opportunity for use of once weekly intravenous antibiotics.” Abbreviations: GNR, gram negative rods; IDU, injection drug user; IV, intravenous; IVDU, intravenous drug use; NH, nursing home; OPAT, outpatient parenteral antibiotic therapy; PICC, peripherally inserted central catheter; PWID, people who inject drugs; SAR, subacute rehab. and/or outpatient programs (n =  41), linking or referring to either inpatient antibiotics or a combination of inpatient and addiction or mental health services (n =  28), working with a outpatient treatment. Respondents’ comments mentioned a multidisciplinary team (n =  26), provider–patient relationship comprehensive referral center, outpatient coordinated ser- (n = 23), and engaging family/support system (n = 15). Other vices, social workers, and primary care provider involvement categories that emerged included challenges around provision as solutions to the difficulties of managing serious infections of comprehensive medical management to PWID and a gen- in people who use drugs. Other comments identified the use eral lack of helpful strategies (n = 30); we described these chal- of long-acting injectable antibiotics, such as dalbavancin and lenges above. Table 5 contains example comments organized by oritavancin, and 1 respondent advised using oral antibiotics category. when possible. Overall, the most frequently mentioned strategy to pro- e s Th econd and third most common strategies were link- vide comprehensive medical management to PWID involved ing or referring to addiction or mental health services, with 28 ID Practice and Injection Drug Use • OFID • 5 Downloaded from https://academic.oup.com/ofid/article-abstract/5/7/ofy132/5034859 by Ed 'DeepDyve' Gillespie user on 16 October 2019 Table  5. “What Strategies Have You Found Particularly Helpful to Providing Comprehensive Medical Management to PWID?” Example Comments by Theme, the Infectious Diseases Society of America Emerging Infections Network, 2017 Using Inpatient and Outpatient Programs “Best in my experience is when hospital/system can provide dedicated specialist to help patient with substance abuse while inpatient and then link to outpa- tient services.” “Nothing short of prolonged inpatient treatment followed by very attentive outpatient follow up from dedicated addiction specialists.” “Using the severe infection as a tool to help the person address underlying issues, and linking the person with in hospital and out of hospital supports.” Linking or Referring to Addiction Services and Mental Health “All hospitals should have a 12-step program (NA or AA) available for patients and community members in need.” “Our outpatient clinic now has a buprenorphine clinic which is excellent but having greater services inpatient would be of great import.” “Buprenorphine providers affiliated with the medical center with easy follow-up with and multiple spots available.” “Getting them referred to a long-term inpatient setting that includes substance abuse treatment and counseling.” “Assessment via addiction medicine specialist to help determine likelihood of relapsing at discharge.” Working With Multidisciplinar y Team “Working w/ a multidisciplinary team on trying to come up with treatment plans and shared expectations for patients with ongoing IV drug use that are going to be admitted for long term.” “Multi-disciplinary approach so it is not solely my responsibility to decide if patient is safe for home OPAT therapy.” “Creation of a separate multidisciplinary team that focuses on inpatient PWID with infection requiring IV.” “Team approach works best...specialization in addiction medicine...also for the patient getting multiple perspectives and REINFORCEMENT of the message to come clean.” Provider–Patient Relationship “A strong personal relationship and appealing to patient’s self-interest.” “Explicit discussion about concerns regarding active IVDU and effect on plan of care.” “Don’t blame the user. Instead offer support until they become hopeful enough to make a successful quit attempt.” “Taking a nonjudgmental approach to interaction with patients appears to lead to more open communication.” Engaging Family/Support System (Utilize Social/Community Services) “Engage patients support system if available to assist in care and help in bridge to rehab program.” “Early social work and family involvement.” “Social services along with hospital and community services need to join in helping drug addiction.” “Working with community-based partners (i.e. needle exchange and MMT) where people are already receiving services.” “Inpatient order sets for patients with SUDs (includes STI screening, narcan prescribing), staff education/teaching lectures, leadership support, capacity building with community organizations.” “Community/peer navigators, outreach workers.” Challenges “Very limited resources, we usually keep in house for 2–3 weeks then try to D/C on PO. No real rehab available, limited chronic pain management.” “The health system will cover hundreds of thousands of dollars for medical management of infectious complications then not cover any rehab.” “Substance abuse treatment is well beyond the scope of ID trained physician.” “Need more healthcare resources to focus on this issue.” “I see no concerted effort from either government or individual hospital systems to deal with this problem.” Abbreviations: AA, Alcoholics Anonymous; D/C, discharge; ID, infectious diseases; IV, intravenous; IVDU, intravenous drug use; MMT, methadone maintenance treatment; NA, Narcotics Anonymous; PO, per oral; OPAT, outpatient parenteral antibiotic therapy; PWID, people who inject drugs; STI, sexually transmitted infection; SUD, substance use disorder. comments, and working with a multidisciplinary team, with 26 Extending beyond the provider–patient relationship, 15 comments. Respondents noted that comprehensive medical man- respondents identified engaging patients’ families or support agement of PWID “works best when combined with some sort systems and using social or community services. In general, of addiction recovery” and a “multidisciplinary approach to care comments suggested that family/support system engagement [is the] only chance of making a difference.” Comments included was helpful to assistance with care, notably getting patients into inpatient drug rehabilitation and linkage to addiction programs outpatient programs or drug rehabilitation programs. With at hospital discharge. A  few respondents specifically identified regard to utilizing social/community services, respondents’ buprenorphine and methadone treatments for opioid use dis- comments reiterated the need for medical management focused order. Other strategies cited included comanagement with syringe on PWID to go beyond treating infections: “Social services exchange programs/substance abuse counseling and targeting along with hospital and community services need to join in social determinants of health with each visit to the health care helping drug addiction.” system. DISCUSSION Twenty-three respondents commented on the provider– patient relationship. Several survey participants reported hav- In this national sample of infectious diseases clinicians, the ing open dialogue with patients about risks. With 6 unique majority of survey participants reported providing care to instances of the term “nonjudgmental,” other comments catego- PWID, suggesting that treatment of serious IDU-related infec- rized within this theme contained words that included “trust,” tion is a common feature of today’s infectious diseases practice “support,” “understanding,” and “patience.” in the United States. For a subset of providers, provision of 6 • OFID • Rapoport et al Downloaded from https://academic.oup.com/ofid/article-abstract/5/7/ofy132/5034859 by Ed 'DeepDyve' Gillespie user on 16 October 2019 care to PWID represents a substantial component of clinical Second, we relied on self-reports and responses, which may be practice. In both multiple choice and open text responses, subject to recall bias. Lastly, given that nonrespondents were physicians highlighted the often complex, resource-intensive significantly more likely than respondents to have less than nature of providing care to PWID, owing to infection sever- 25  years of ID experience, the findings of the survey may not ity (frequently requiring >2 weeks of parenteral antibiotic represent the experience of younger respondents. This is par - treatment) and structural barriers to conventional manage- ticularly noteworthy, as clinicians in practice for <5 years were ment (psychosocial complexity and lack of insurance, among significantly more likely to treat PWID (89%) compared with others). senior clinicians with ≥25 years of experience (67%, P < .0001). Our results demonstrate an overall lack of resources for ID er Th efore, follow-up queries targeting the experience of infec- physicians treating PWID. For example, only a small number tious diseases providers in earlier stages of practice may better of ID providers queried (10%, n =  51) strongly agreed that reflect the full range of experiences and challenges relevant to their care setting provided comprehensive substance use treat- caring for PWID. ment, highlighting that the majority of providers treat complex In the setting of the escalating opioid crisis, complex care infection in PWID who lack access to treatment for underlying requirements for PWID will persist, highlighting the need for opioid use disorders. Respondents expressed diverse opinions guidelines and further research to identify best practices for regarding the potential role for ID providers in the management management. Expansion of ID providers’ clinical purview to of addiction, and acquisition of a federal waiver to prescribe integrate concurrent addiction treatment and harm reduction buprenorphine was rare among respondents, commensurate represents 1 novel element that merits further consideration. with national data reporting that approximately 4% of practic- Acknowledgments ing physicians have waiver certification [16]. e a Th uthors thank Brian Edlin, Robert Pinner, and Toby Merlin for their Given the challenges facing ID physicians caring for an review of and helpful input on the manuscript.  increasing number of PWID, our results suggest that public Financial support. This publication was supported by Cooperative health and health care officials should consider ways to enhance Agreement Number 1 U50 CK000477, funded by the Centers for Disease Control and Prevention. Its contents are solely the responsibility of the the evolving role of ID physicians in the care of PWID. The authors and do not necessarily represent the official views of the Centers for IDSA could consider the development of guidelines, a research Disease Control and Prevention or the Department of Health and Human agenda to identify knowledge gaps, and other resources to Services. Potential conifl cts of interest. All authors: no reported conflicts of address the complex care of PWID, including safe provision of interest. All authors have submitted the ICMJE Form for Disclosure of multiweek parenteral therapy. Hospitals and health care systems Potential Conflicts of Interest. Conflicts that the editors consider relevant to can consider ways to improve comprehensive substance use dis- the content of the manuscript have been disclosed. order treatment, including use of multidisciplinary teams, link- age to addiction or mental health services, syringe exchange References 1. Centers for Disease Control and Prevention. 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Clin Infect Dis 2016; 62:99–105. tion-and-moc. Accessed 16 September 2017. 8 • OFID • Rapoport et al Downloaded from https://academic.oup.com/ofid/article-abstract/5/7/ofy132/5034859 by Ed 'DeepDyve' Gillespie user on 16 October 2019 ID Practice and Injection Drug Use • OFID • 9 Downloaded from https://academic.oup.com/ofid/article-abstract/5/7/ofy132/5034859 by Ed 'DeepDyve' Gillespie user on 16 October 2019 10 • OFID • Rapoport et al

Journal

Open Forum Infectious Diseases – Oxford University Press

Published: Jul 1, 2018

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