Author + information
- Richard J. Kovacs, MD, FACC, President, American College of Cardiology∗ (, )
- Jason H. Gilbert, PhD, MBA, RN, NEA-BC, Chief Nursing Officer, Indiana University Health and
- William J. Oetgen, MD, MBA, FACC, Clinical Professor of Medicine, Georgetown University
- ↵∗Address for correspondence:
Dr. Richard J. Kovacs, American College of Cardiology, 2400 N Street NW, Washington, DC 20037.
A review published by The Doctors Company noted that nearly 10 million Americans take prescribed opioids on a long-term basis, with 5 million reporting use of opioids without a prescription (1). As these numbers increase, so does the number of deaths. According to a recent paper in Health Affairs, opioid drug deaths increased 371% between 1999 and 2016 (2). New statistics from the U.S. Department of Health and Human Services show 47,600 people died from overdosing on opioids in 2018. Broken down by day, this is roughly 130 people dying every day from opioid-related overdoses (3). Cardiovascular medicine and surgery are not untouched by this national epidemic.
With no real signs of reversing the opioid trends, the medical community as a whole is starting to feel the impacts. “We haven’t seen the peak yet. I think we’re cresting; we’re getting to the point where we are maybe going to start making some progress towards getting to the peak, but it’s still going to get worse before it gets better,” said Craig J. Beavers, PharmD, co-chair of the American College of Cardiology (ACC) clinical pharmacist workgroup, in a recent interview in the College’s member magazine, Cardiology (4).
A study presented at ACC’s 2019 Annual Scientific Session in New Orleans showed the number of patients presenting with acute coronary syndrome (ACS) as a result of drug abuse increased from 168 per 100,000 quarterly ACS admissions up to 315 per 100,000 in 2015, while overall ACS admissions decreased. Researchers reported that these patients were younger, of lower socioeconomic status, and had higher rates of smoking and chronic kidney disease (5).
Another study published in the Journal analyzed the National Readmissions Database and found that the number of Americans hospitalized for infective endocarditis (IE) caused by injection drug use (IDU) nearly doubled from 15.2% to 29.1% between January 2010 and September 2015. Those with IDU-IE were younger and had fewer comorbidities, the researchers said. Approximately 11% of the IDU-IE patients underwent valve surgery to replace the mitral or aortic valve (6).
In both cases, drug abuse was related to increased inpatient mortality and longer hospital stays. In the IE study, researchers noted that compared with nondrug-related IE, patients with drug-related IE who were managed medically had significantly longer hospital stays and were more likely to be readmitted for endocarditis, septicemia, and drug abuse. When managed surgically, these patients also required greater resource use, with longer length of stay and more readmissions for septicemia and drug abuse (6).
The results from these and other studies like them provide a snapshot into the new issues being faced by clinicians, hospitals, and practices. The American Society of Addiction Medicine notes that “prevention efforts and treatment approaches for addiction are generally as successful as those for other chronic diseases,” but demographic factors like age and socioeconomic status, coupled with the fact that most people battling addiction “use substances or engage in behaviors that become compulsive and often continue despite harmful consequences” pose unique challenges (7).
A younger patient population with fewer comorbidities can mean more hospital visits and treatments over the course of a person’s lifetime. Given the limited socioeconomic means of many opioid users, affording (and sustaining) long-term treatment plans, including medication, follow-up appointments, and mental health and addiction support, can be even more difficult. The Doctors Company study of 272 opioid-related claims that were closed between 2017 and 2015 found that patient factors, including noncompliance with treatment plans and follow-up appointments, were among the top reasons for poor outcomes (1).
Patient care is not the only challenge. “In addition to the national focus on opioid-related overdose and mortality, it is imperative to understand how opioid use can affect a patient's relationship with the health care system,” according to Liberman et al. (8), in a study published earlier this year in the Journal of the American Heart Association that looked at the association between opioid prescriptions at hospital discharge and post-discharge health care utilization (8).
Further complicating the challenges that health care systems face in designing programs to care for IDU/IE is the societal stigmatization of addiction. Over the past decade, health care systems have been working to implement screening, brief intervention, and referral to treatment interventions to aid in detection and treatment referral of IDU patients (9). Despite implementation of these programs, significant stigmatized barriers to post-acute care exist in many communities for patients with a history of IDU or those on opioid agonist therapy. Patients with infectious complications who require post-acute care in conjunction with addiction treatment programs are particularly at risk for longer hospital stays and increased incurred cost due to lack of community resources (10).
In today’s evolving health care environment where reducing health care costs and hospital readmissions are increasingly tied to reimbursement, the longer hospital stays, repeat readmissions for additional drug-abuse issues, and potentially invasive surgical interventions associated with treating opioid users also pose resource, cost, and treatment challenges to hospitals and providers.
Costs and ethics are fueling much debate and discussion in the medical field. For example, Mary Norine Walsh, MD, MACC, highlighted some of the issues with surgically treating IDU-IE patients in the Cardiology piece. “I think the decision to operate the first time is usually fairly straightforward, but it’s the re-do valve operations, when the prosthetic valve gets infected because of continued drug use, where people are struggling. I believe there are some surgeons who say they won’t re-operate on these patients and others who do” (4). Although the economic and resource-management concerns reflected by withholding re-operation may be understandable, the concomitant ethical and liability implications of this position are staggering.
The American Society of Addiction Medicine earlier this year released a public policy statement on “Medical Ethics with Annotations Applicable to Addiction Medicine” that states “a physician shall support access to medical care for all people” and notes that “addiction treatment should be a component of this care.” The statement goes on to provide recommendations ranging from offering and participating in training and use of evidence-based interventions to prevent “the unhealthy use of alcohol, nicotine, and other substances,” to providing “evidence-informed, integrated substance use disorder treatment services for patients.” It also recommends active participation in community coalitions and local, state, and federal legislative/regulatory processes, as well as use of Prescription Drug Monitoring Programs and screening, brief intervention, and referral to treatment efforts (11).
It is no surprise given these discussions that opioid-related claims are a common cause of litigation. Inappropriate selection and management of therapy, errors in patient monitoring, inadequate patient assessments for risks and contraindications to opioids, failure in communications among providers, and insufficient documentation and/or support for clinical decision making were among the top factors for claims, according to The Doctors Company (1). Furthermore, Yang et al. (12) have emphasized the significant civil liability, criminal liability, and professional sanctions faced by physicians who inappropriately prescribe opioids.
To help mitigate the clinical and medical liability risks, the Centers for Disease Control and Prevention (CDC) in March 2016 released specific recommendations to help clinicians. Among the suggestions: documenting “a detailed history, physical findings, and lab or imaging findings, and provide a diagnosis and rationale for pain management,” and using “the lowest effective immediate-release dose when prescribing opioids for acute pain.” The CDC list also includes discussing known risks of opioids with patients; reevaluating patients every 3 months to assess for risks; and referring or offering treatment for patients identified as having an opioid use disorder (13).
Many state medical boards also now require documentation prior to opioid prescriptions of an established physician-patient relationship; a history and physical, diagnosis of pain condition, objective studies, expectation of the treatment’s effects, documentation of each prescription, and reasons for early refills and changes; a discussion of alternative therapies and substance abuse; a Prescription Drug Monitoring Program consultation; and monitoring the effectiveness of therapy, dependence, and withdrawal (12).
Workforce issues, particularly clinician burnout, are another area where opioids are taking a toll on the health system. According to a recent article published in PLOS One, nurses on the front lines of treating addiction patients cited factors “related to managing patients’ pain, overall communication, and threats to personal safety” as key contributors to feelings of burnout. “Workplace violence has been associated with increased rates of burnout, job dissatisfaction, and decreased productivity among nurses; accumulated stress in working with people who use drugs translates to higher rates of intention to change jobs,” the paper states (14). Additionally, in many cases health care clinicians are often placed in an “authoritative” or “policing” role versus a caregiving role (14). One can safely assume these same factors would be cited by cardiovascular clinicians across the entire care team, from physicians to pharmacists.
So, what can we do? On the patient-management side, we continue to do what we promised to do when we graduated professional school to the best of our ability and judgment—“first do no harm.” However, it is more important than ever to screen patients for risk, document family history, and educate ourselves, our patients, and their families and support networks about addiction risks and treatment options. We must also recognize that we—the care team—are all in this together. Education must begin at the very top of the health system chain and be sustained across physicians, nurses, pharmacists, and trainees. Safe and supportive hospital and practice environments are the key to success for all.
In addition, do not underestimate the power of community engagement and advocacy with lawmakers, health plans, and local community leaders. The power of a dedicated group of people speaking with 1 voice on behalf of their patients is unparalleled. This is an issue that, if addressed now, could not only mean better patient outcomes, but also help to reduce health care costs and improve clinician well-being. The modern Hippocratic Oath reminds us all that we “remain a member of society, with special obligations to all my fellow human beings, those sound of mind and body as well as the infirm” (15). If we start with this in mind, we can no doubt bring change.
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