Psychosomatics 2020:61:678–687 ª 2020 Academy of Consultation-Liaison Psychiatry. Published by Elsevier Inc. All rights reserved.

Original Research Article

Addiction Management in Hospitalized Patients
With Intravenous Drug Use–Associated Infective
Endocarditis

Vani Ray, M.D., Mindy R. Waite, Ph.D., Frank C. Spexarth, R.Ph., Sandra Korman, M.S.,
Susan Berget, M.S.N., R.N., Soumya Kodali, M.D., David Kress, M.D., Neil Guenther, M.D.,
Vishnubhakta S. Murthy, M.D.

Background: Infections related to intravenous drug use
and opioid use disorders (OUDs) are increasing
nationwide. Endocarditis is a recognized complication
of intravenous drug use, and inpatient treatment typi-
cally focuses on infection management without atten-
tion to underlying addiction. Objective: A comprehensive
intervention for inpatients with infective endocarditis and
intravenous drug use was implemented by a multidisci-
plinary team at a large midwestern hospital. The team
included behavioral health/addiction medicine, infectious
disease, pain medicine, cardiothoracic surgery, pharmacy,
and nursing to address the OUD while managing the
infection. The intervention was assessed by measuring the
initiation of medication-assisted treatment and
endocarditis-related readmissions. Methods: Patients were
identified from the medical records using discharge diag-
nosis codes for OUDs and infective endocarditis. In addi-
tion to medical management of infective endocarditis, the
multidisciplinary intervention included early involvement of
addiction medicine and the pain management at the time of
admission. Patient interventions included education, moti-
vational interviewing, behavioral health engagement,
collaborative pain management, individual/family therapy,
medication evaluation, and initiation of medication-assisted
treatment. Caregivers were also educated on OUDs and
ways to support patients undergoing interventions. Results:
Both the historical control group (N = 37) and the inter-
vention group (N = 33) were comparable in age, gender,
race, marital status, psychiatric history, and smoking but
differed by employment status, religious affiliation, and use
of psychiatric medications. At discharge, 18.9% of the
control group and 54.5% in the intervention group were
initiated on medication-assisted treatment for OUDs. No
differences in readmission rates were found. Conclusion:
Multidisciplinary teams for treating inpatients with intra-
venous drug use and infective endocarditis are feasible and
can increase the uptake of OUD-specific treatment.
(Psychosomatics 2020; 61:678–687)

Key words: medication-assisted treatment, opioid use disorders, addiction, cardiovascular surgery, multidisci-
plinary team, inpatient.

INTRODUCTION
Substance use disorders are associated with numerous
complications leading to morbidity and mortality.
Mortality due to opioid use disorder (OUD) has
increased dramatically over the last several decades.1
Concomitant with the increase in illicit use of opioid
pain relievers is the recent nationwide increase in use of
the illicit opioid, heroin. From 2003 to 2013, heroin use
has doubled, and the deaths associated with heroin
abuse have nearly quadrupled.2 A divide previously
Received May 19, 2020; revised June 24, 2020; accepted June 25, 2020.
From the Aurora Behavioral Health Services (V.R., M.R.W.), Advocate
Aurora Health, Wauwatosa, WI; Aurora Research Institute (M.R.W.),
Advocate Aurora Health, Wauwatosa, WI; Department of Pharmacy
Services (F.C.S.), Aurora St. Luke’s Medical Center, Advocate Aurora
Health, Milwaukee, WI; Department of Quality Management (Sandra
Korman), Aurora St. Luke’s Medical Center, Advocate Aurora Health,
Milwaukee, WI; Department of Nursing (S.B.), Aurora St. Luke’s
Medical Center, Advocate Aurora Health, Milwaukee, WI; Aurora
Cardiovascular and Thoracic Services (Soumya Kodali, D.K., N.G.,
V.S.M.), Aurora St. Luke’s Medical Center, Advocate Aurora Health,
Milwaukee, WI. Send correspondence and reprint requests to Vani Ray,
MD, Aurora Behavioral Health Services, Advocate Aurora Health, 1220
Dewey Ave., Wauwatosa, WI 53213; e-mail: publishing675@aurora.org
ª 2020 Academy of Consultation-Liaison Psychiatry. Published
by Elsevier Inc. All rights reserved.

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existed between populations illicitly using prescription
opioids versus heroin, whereas now, almost half of
patients with OUDs report use of both prescription
opioids and heroin.3 This shift in drug use has impacted
associated hospitalizations, as hospitalizations of both
OUD and infections resulting from injections of illicit
drugs, such as heroin, have increased drastically during
the same time period.4
Infective endocarditis (IE) is one of the more serious
complications of intravenous drug use (IVDU) and has
high morbidity and mortality rates, often due to result-
ing congestive heart failure. IE is caused by bacterial or
fungal infections within the heart and is typically a result
of valvular heart disease in the general population.
However, in a subpopulation of patients, IE is caused by
IVDU (IVDU-IE). Comparatively, typical patients with
IE are older, more likely to have hypertension and heart
disease, and more likely to have other comorbid disor-
ders associated with age than their IVDU-IE counter-
parts.5 The incidence of IE has risen slightly in the
general population, whereas the incidence of IVDU-IE
has more than doubled in the last decade and currently
accounts for around 10% of IE diagnoses.6 Concomitant
with the increase in IVDU-IE, rates of hospitalization
and surgery associated with IVDU-IE have increased,5,7
as has the frequency of IVDU-IE–related death.8
Regardless of cause, IE treatment is extremely
resource intensive and often involves long-term intra-
venous (IV) antibiotic treatment, long inpatient hospi-
talizations, and surgical intervention for valve
replacement, wherein approximately 60% of patients
with IE and IVDU-IE will require surgery.9 The cost
for IVDU-IE is double that for IE in patients without
IVDU,10 and patients with IVDU-IE tend to be white,
male, low income, and on Medicaid or uninsured,6,11
although women are more prevalent in some age
groups.7 Patients with IE are also typically young (aged
20–40 y),7,9 especially as compared with patients with
IE not associated with IVDU.5,12
Because many patients with IVDU-IE are younger,
they would benefit from many years of added life ex-
pectancy resulting from surgical intervention. Further-
more, they are physically better candidates for surgery
in that they have lower surgical risk scores and also
better short-term outcomes.5 Nevertheless, owing to the
chronic and cyclical nature of IVDU, this subpopula-
tion of patients with IE has a much higher rate of valve
reinfection than their IE counterparts and longer term
mortality than expected for this age group.5,12
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Ray et al.
Reinfection results in increased mortality risk13,14 and
additional heavy resource needs for further
treatments.5,15
As a result of this risk for reinfection due to
continued IVDU, there is considerable controversy
regarding the most effective, efficient, and ethical
treatments for IVDU-IE. For example, IV antibiotics
are the standard of care for endocarditis therapy with
or without surgical intervention, and outpatient
parenteral antimicrobial therapy is effective in man-
aging less-severe IE.16 However, outpatient parenteral
antimicrobial therapy should not be prescribed for pa-
tients with IVDU-IE out of concern that the IV line
may be repurposed for and thereby facilitate further
illicit drug use,17,18 although this concern appears un-
founded.19 Even the initial surgery and/or reoperations
for patients with IVDU-IE may be controversial owing
to the concern of relapse and long-term risk.20,21
To mitigate these risks, physicians may advise
prolonged hospitalization or completion of IV drug
therapy at rehabilitation facilities.16,18 However, full-
risk mitigation requires addressing the substance use
disorder causing the IE. Comprehensive approaches to
substance use disorder typically include psychotherapy,
medication-assisted treatments (MATs), and safe envi-
ronments for recovery, yet many hospitals lack
comprehensive teams and protocols to manage addic-
tion,9,15 especially because the average inpatient is
admitted for relatively brief durations. In contrast,
hospitalization for endocarditis treatment is often 6
weeks in duration and enables comprehensive, multi-
disciplinary approaches with several opportunities to
start, optimize, and potentially maintain substance use
treatments, including MAT.22
MAT options offer benefits in maintaining absti-
nence by decreasing opioid cravings and illicit opioid
use, as well as improving retention in outpatient treat-
ment programs. As a result, the National Institute of
Drug Abuse and Substance Abuse and Mental Health
Services Administration have indicated that providers
have an important role in augmenting interventions by
expanding MAT for OUDs.23 Despite numerous
studies demonstrating the effectiveness of MAT for
OUDs, only a small percentage of patients with OUD
receive access to MAT.24 This low rate of use is a result
of stereotypes/stigma, limited accessibility or availabil-
ity, restrictions on locations for MAT receipt, treatment
cost, belief that they do not have a problem, or their
desire for continued opioid use.25–27
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Addiction Management in Patients With IV Drug Use-Associated Endocarditis
As a result, the incorporation of psychotherapy and
MAT as part of inpatient stays may offer critical
treatment and outpatient linkages for patients with
IVDU-IE who may otherwise be unable or unwilling to
access therapy. This ability to springboard substance
use treatment while people with substance use disorders
are easily accessible as inpatients is a key reason to
incorporate multidisciplinary teams with behavioral
health experts into inpatient treatment.28
Incorporating substance use treatment and outpa-
tient connections during the inpatient experience would
require an expanded and multidisciplinary team,
updated treatment protocols, and inclusion of sub-
stance use goals to include therapies such as MAT and
psychotherapy. One study tested a comprehensive
intervention targeting increased MAT prescription for
patients with IVDU-IE and found a 62% rate of
acceptance.22 However, control groups were not avail-
able for comparison, and no studies have tested the
feasibility or comparative outcomes of a comprehensive
treatment program for patients with IVDU-IE.
The purpose of this retrospective study was to
evaluate the feasibility of implementing of a compre-
hensive, multidisciplinary treatment approach in the
management of patients with OUD admitted to car-
diovascular surgery for medical or surgical treatment
for IVDU-IE at a large midwestern hospital. The sec-
ondary purpose was to determine whether imple-
mentation of this approach resulted in greater patient
access to MAT and reduced readmissions.
METHODS
Study Design
The site was a 938-bed community-based quaternary
care hospital in Milwaukee, Wisconsin. Preliminary
practice evaluations had previously identified inconsis-
tent addiction management of patients being treated for
IVDU-IE. Before this intervention, patients were
treated primarily for IE, and the underlying addiction
was not consistently addressed. As a result, an inter-
vention was developed, which included education,
development and utilization of targeted care pathways,
and the creation of a multidisciplinary team that
included representatives from cardiovascular surgery,
behavioral health/addiction medicine, pain medicine,
pharmacy, cardiac nursing, and social work. The
department of cardiovascular surgery and psychiatry/
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addiction medicine established a quality improvement
committee to address identified issues in our patient
population. The project used the Institute of Healthcare
Improvement process of quality improvement using a
standardized Plan-Do-Study-Act process.
The committee identified that underlying addiction
in patients with IVDU-IE was not consistently
addressed. As a result, patients struggled with acute
withdrawals, cravings, visitors attempting to bring
illicit substances into patient rooms, and discharges
against medical advice (AMA) resulting in relapse on
IV drugs during postoperative period after complex
surgeries. To remedy the deficiencies in the care of these
patients, clinicians with expertise in treating this com-
plex patient population were identified as primary
intervention providers. The multidisciplinary team
developed a cardiac surgery care medication pathway
for patients with OUD (Figure 1). These pathways
included recommendations for preoperative manage-
ment of patients with OUD on MAT, perioperative
medication changes to reduce opioid requirements
during recovery from the surgery by starting nonopioid
therapies (gabapentin, acetaminophen) before surgery,
postoperative pain control, and transition planning for
outpatient MAT.
Once patients with IVDU-IE were identified, a
thorough assessment was made regarding the fre-
quency, duration, intensity, last use of the IV opioids,
nature of withdrawal symptoms, and other substance
use (such as alcohol) by the nursing staff. A urine
toxicology screen was obtained at the time of admission
and subsequently repeated as needed, dependent on
patient behavior while inpatient.
Given the increased tolerance to opioid pain med-
ications29 and the recidivism associated with OUD, a
pain management specialist (anesthesiologist) and a
physician certified in addiction medicine were consulted
at admission so as to appropriately manage drug ther-
apy for postoperative pain, help coordinate transitions
to MAT, and address acute withdrawal needs, consis-
tent with previous recommendations.30 Postoperative
pain management expectations were explained to pa-
tients and a plan developed according to the cardiac
surgery care medication pathway for patients with
OUD. Furthermore, a substance use counselor part-
nered with the psychiatrist/addiction specialist who
addressed the substance use by providing individual
and family counseling with psychoeducation, setting
goals, identifying risk factors/triggers for relapse, and
Psychosomatics 61:6, November/December 2020
 Ray et al.

FIGURE 1. Treatment algorithms for patients with IVDU-IE during inpatient stay (A) and at discharge (B).

IVDU-IE = infective endocarditis is caused by intravenous drug use; LTAC = longterm acute care.

developing strategies for abstinence. This ensured the
individual goals of the patient were being met while
stabilizing patients on OUD medications, prescribing
medications at discharge, and establishing outpatient
OUD treatment programs to maintain abstinence.
Advanced practice nursing and the unit-based
clinical nurse specialist worked in collaboration to
provide caregiver education and developed/imple-
mented safety practices specific to patients with IVDU.
This procedure addressed family visits, patient obser-
vation practices (e.g. keeping patient doors open during
the day), and risk of illicit IV drug use in the patient
room (e.g. removing used needle containers, screening
visitors, and so on). In addition, social work and case
management were incorporated to address housing,
insurance, and transportation issues to increase the
likelihood of attendance at outpatient appointments on
discharge.
Patients requiring long-term IV antibiotics were
either kept within the hospital or transferred to long-
term acute care facilities. Suboxone was initiated in
the hospital and maintained by addiction/psychiatry if
they stayed until discharge. If the patient was trans-
ferred to a long-term acute care facility, alliances were

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Addiction Management in Patients With IV Drug Use-Associated Endocarditis
made between the long-term acute care facilities and
community physicians to continue suboxone until the
patients were discharged to go to the outpatient sub-
oxone maintenance clinics.
After the pathway was developed, physician order
sets were updated to carry out programmed orders.
Caregiver education on the new OUD pathways, order
set changes, and generalized OUD was created and
implemented for nursing/provider education to ensure
consistent messaging and safe treatment of these pa-
tients. After education, the intervention was partially
implemented in January 1, 2017 and fully implemented
by April 1, 2017.
The local institutional review board acknowledged
this study as a not-human-subjects-research quality
improvement effort.
Patient Population
Data were limited to adult ($18 y of age) inpatients
admitted with diagnoses of both endocarditis and 1 or
more opioid-related use disorders. Diagnoses for
opioid-related disorders and endocarditis were identi-
fied using international classification of diseases (ICD)-
9 and ICD-10 diagnosis codes (Supplementary
Table 1). IVDU was confirmed by patient self-report.
Records were divided into preintervention and post-
intervention cohorts, whereby the preintervention
group was selected based on discharge date and
included patients discharged between January 1, 2015
and December 31, 2016. To ensure that hospitalizations
of patients in the postintervention cohort began after
the intervention was fully implemented, patients in this
group were selected based on admission date. The
postintervention cohort spanned a 1-year period and
included patients admitted between April 1, 2017 and
March 31, 2018. Some patients were hospitalized mul-
tiple times for endocarditis and opioid- or cocaine-
related disorders over the time periods included in this
evaluation. In such cases, each hospitalization was
included in the analysis as a unique observation with 1
exception: when patients were discharged AMA and
chose to return to the hospital within 2 days of
discharge, the 2 hospitalizations were considered a
single observation.
Measurements
Outcomes measured included completion of a behav-
ioral health consultation before discharge, MAT on
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discharge, inpatient length of stay, 90-day readmissions
for any reason, and 90-day readmissions for endo-
carditis. Behavioral health/addiction medicine consults
during hospitalization were obtained by reviewing
progress notes in patient charts and requested once
acuity of the medical condition resolved. The consult
team comprised the psychiatrist/addiction specialist and
the substance abuse counselor and assessed opportu-
nities for MAT initiation. MAT on discharge was
determined by reviewing the patient chart and the
Wisconsin Prescription Drug Monitoring Program,
wherein buprenorphine prescriptions filled within (60)
days of discharge were used to identify patients on
MAT. The delay in filling prescriptions for MAT was
chosen to account for patients with postoperative
complications, delayed wean from narcotics, and pa-
tients discharged to long-term acute care facilities for
IV antibiotic therapy. Ninety-day readmission was
determined through manual chart review by assessing
for same-hospital admissions within 90 days of the
discharge date. Patient demographics were also
collected.
Statistics
For categorical variables, comparison between the
preintervention and postintervention groups were
completed using the chi-squared test or, when at least
25% of the cells had an expected sample count of less
than 5, Fisher’s exact test. For categorical variables,
comparison between the preintervention and post-
intervention groups was completed using the
Kolmogorov-Smirnov two-sample test.
RESULTS
Population/Patient Selection
The study population included 70 eligible patients: 37
in preintervention group and 33 in postintervention
group (Figure 2). In the preintervention group, 57
unique hospitalizations were initially identified for in-
clusion for the study. Four cases were initially excluded
because the patients were on chronic opioid therapy,
and 1 case was excluded because the patient was mis-
coded as having an IVDU history. Eight cases required
combining 2 sequential hospitalizations because the
patient was discharged AMA and then readmitted
within 2 days of discharge, resulting in a total of 44 pre-
intervention hospitalizations. Seven additional
Psychosomatics 61:6, November/December 2020
 Ray et al.

FIGURE 2. Patient eligibility based on inclusion/exclusion from the total IVDU-IE population.

IVDU-IE = infective endocarditis is caused by intravenous drug use.

hospitalizations were excluded because 5 patients were
discharged AMA and 2 patients expired in the hospital.
In the postintervention group, 50 unique hospitaliza-
tions were initially identified for inclusion for the study.
Two cases were initially excluded because chart reviews
indicated the patients were on chronic opioid therapy.
There were 5 cases where a hospitalization was com-
bined with a prior hospitalization because the patient
was discharged AMA and then readmitted within 2
days of discharge, resulting in a total of 43 pre-
intervention hospitalizations. Finally, 10 additional
hospitalizations were excluded because 8 patients were
discharged AMA and 2 patients expired in the hospital.
Demographics
Demographic comparisons of patients in the pre-
intervention and postintervention groups are shown in
Table 1. Patients in the postintervention group were
significantly more likely to be employed and to report a
religious affiliation and less likely to be on psychiatric
medication than patients in the preintervention group.
No significant differences were observed between the 2
groups in terms of age, gender, race, marital status,
current smoking status, psychiatric treatment history,
hospitalization type (surgical or medical), or prior
endocarditis.
Comprehensive Treatment Team Intervention
Outcomes
Analyses of outcomes suggested some significant dif-
ferences between the preintervention and post-
intervention groups (Table 2). There was a significant
difference in the completion of a behavioral consulta-
tion between groups in that 100% of patients in the
postintervention group received a behavioral consulta-
tion, whereas only 78% of the preintervention group

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Addiction Management in Patients With IV Drug Use-Associated Endocarditis

TABLE 1. Characteristics of Preintervention and TABLE 2. Outcome Comparisons Between the Preintervention
Postintervention Patient Groups and Postintervention Groups
Demographics Preintervention Postintervention P-value Measure Preintervention Postintervention P-value
Total N 37 33 Behavioral 29 (78.4%) 33 (100%) 0.006
Age, Median 31 (18–54) 31 (25–52) 0.72 consultation
(Range) completed, N (%)
Male, N (%) 16 (43.2%) 14 (42.4%) 0.99 MAT on discharge 0.003
Race, N (%) 0.78 MAT consult and
American Indian 2 (5.4%) 1 (3.0%) initiation status
Black 4 (10.8%) 2 (6.1%) No MAT consult 13 (35.1%) 5 (15.2%)
Hispanic 1 (2.7%) 0 MAT consult
White 30 (81.1%) 29 (87.9%) performed
Unknown 0 1 (3.0%) No MAT 17 (46.0%) 10 (30.3%)
Marital Status, 0.53 initiated
N (%) Methadone 4 (10.8%) 2 (6.1%)
Divorced 1 (2.7%) 4 (12.1%) Naltrexone 1 (2.7%) 4 (12.1%)
Married 1 (2.7%) 1 (3.0%) Buprenorphine/ 2 (5.4%) 12 (36.4%)
Separated 1 (2.7%) 1 (3.0%) naloxone
Single 34 (91.9%) 27 (81.8%) (Suboxone)
Current Smoker, 32 (86.5%) 31 (93.9%) 0.43 LOS, Median 14 (3–55) 17 (2–54) 0.83
N (%) (Range)
Employed, N (%) 1 (2.7%) 6 (18.2%) 0.046 90-D readmission for 16 (43.2%) 13 (39.4%) 0.74
Any Religious 5 (13.5%) 15 (45.5%) 0.004 any reason, N (%)
Affiliation, N (%) 90-D readmission for 8 (21.6%) 9 (27.3%) 0.58
Psychiatric 27 (73.0%) 26 (78.8%) 0.59 endocarditis, N (%)
Treatment Drug use at 90-d 9 (56.3%) 5 (38.5%) 0.34
History, N (%) readmission for
Psychiatric 27 (73.0%) 13 (39.4%) 0.008 any reason, N (%)
Medication Use, 6-Month reoperation 5 (13.5%) 3 (6.1%) 0.56
N (%)
Surgical 25 (67.6%) 16 (48.5%) 0.15 LOS = length of stay; MAT = medication-assisted treatment.
Hospitalization,
Bold values are statistically significant (P , 0.05).
N (%)
Prior Endocarditis, 23 (62.2%) 19 (57.6%) 0.81
N (%)
DISCUSSION
Bold values are statistically significant (P , 0.05).
Providing optimal care for patients with IVDU and a
life threatening infection is an increasing problem for
many medical centers.6 Although acute management of
did. There was also a significant difference in the pro- IE includes antibiotic use and surgical intervention,
portion of patients in the preintervention and post- long-term avoidance of IE recurrence and survival are
intervention groups who received MAT at discharge. strongly dependent on ceasing IVDU after IE treat-
Only 18.9% of the preintervention group received MAT ment.12 As such, treatments for IVDU-IE are incom-
at discharge, whereas the frequency increased to 54.5% plete without addressing the underlying cause:
in the postintervention group. Consistent with this, the addiction. The ideal treatment for addiction includes
percentage of patients receiving a MAT consult psychosocial support and MAT; however, given the
increased significantly in the postintervention group. level of risk and heavy resources necessary to treat each
There were no significant differences in length of stay, incidence of IVDU-IE, hospitals must implement
readmissions, drug use at readmission, or reoperations. significantly more comprehensive treatment approaches
Similarly, there was no statistical difference between addressing addiction to avoid repeat medical encoun-
readmission curves for the preintervention and post- ters in this population.
intervention groups (Figure 3). No significant differ- These results demonstrate that it is feasible to
ences were observed in the proportion of patients who provide comprehensive interventions to patients during
were discharged AMA or the proportion of patients hospitalization for IVDU-IE using a multidisciplinary
who expired while in the hospital. treatment team and comprehensive intervention

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FIGURE 3. Kaplan-Meier curve for readmission analysis. Solid line
indicates readmissions over time for patients with IVDU-
IE during preintervention and dotted line indicates
readmissions during postintervention.
IVDU-IE = infective endocarditis is caused by intravenous drug use.
pathways managing preoperative initiation of MAT,
postoperative pain control, and transitions to outpa-
tient MAT. Application of these pathways by the
multidisciplinary team significantly increased the
completion rate of behavioral consultations, delivery of
MAT, and rate of MAT uptake at or before discharge.
Importantly, the application of these pathways did not
increase the length of stay.
Results are consistent with those of previous studies
testing comprehensive treatment approaches for IVDU-
IE, although the availability of behavioral consults and
MAT prescriptions here, even preintervention, were
higher than in previous studies.9 Larger scale compre-
hensive interventions in the OUD inpatient population
demonstrated increases in abstinence duration and de-
creases in health care utilization.27
A similar initiative aimed at increasing MAT for
patients with IVDU-IE showed parallel rates of MAT
at discharge (62%).22 Other studies targeting the
broader inpatient substance use population for incor-
poration of comprehensive treatment interventions
demonstrated that 42% of inpatients with OUD were
agreeable to MAT initiation.31 Furthermore, 50–80%
of patients initiating MAT continued into treatment
as outpatients.31–33 As a result, increasing MAT initi-
ation while inpatient is critical because MAT initiation
before discharge is correlated with significant long-term
treatment success.
Lack of access to appropriate medical providers is
one barrier to substance use treatment.34 This
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Ray et al.
intervention takes advantage of the patients’ requisite
inpatient hospitalization to overcome this barrier and
offer critical substance use treatment and planning.
However, for best outcomes, the treatment provided
must be comprehensive, which requires inclusion of
substance use specialists on a multidisciplinary care
team and education for nonspecialists. The education
component is likely to be especially critical given the
many reports that most physicians may not feel
adequately trained to address substance use disorders
and the social stigma.35 Management of IVDU-related
IE should thus shift toward multidisciplinary teams
involving psychiatry, infectious disease, cardiology, and
cardiac surgery, as well as social workers. Such in-
terventions and structured programs, including patient
navigator programs, have been shown to reduce read-
mission rates and improve outcomes for at-risk patients
in other areas of the medical field.36,37
A limitation of the study was the relatively small
sample size as a result of the infrequency of eligible pa-
tients. Potentially as a direct result of the small sample
size, the multidisciplinary intervention did not statisti-
cally reduce readmission and/or endocarditis recurrence.
However, assuming a true readmission rate for pre-
intervention patients was 45%, the power to detect a
20% proportion difference between the 2 groups with an
alpha value of 5% was only 39%. Further, patients were
not followed prospectively to assess the long-term impact
of the intervention, and mortality data were not avail-
able, thereby limiting the ability to compare mortality
between groups, which is an important outcome.
Clinical limitations for implementation could
include a lack of case management components to
address complex psychosocial illnesses and limitations
related to the ability to staff the multidisciplinary team
that relies on access to dedicated pain management and
addiction specialists. Furthermore, long-term mainte-
nance of patient results requires established outpatient
providers to continue MAT posthospitalization, which
may be limited depending on the geographical area and
other social determinants of health.
In addition to increasing the number of patients
receiving necessary substance use therapy, this process
improvement project accomplished several objectives:
1. The organization recognized the need for dedicated
substance use treatment for this vulnerable,
resource-heavy population and created a dedicated
substance use counselor position.
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Addiction Management in Patients With IV Drug Use-Associated Endocarditis
2. Systemwide education was developed to improve the
awareness of addiction principles.
3. Involved providers (nursing, pharmacy, primary
care physicians, and advanced practice clinicians
[APCs]) received targeted education on substance
use, MAT, and patient engagement, thereby
improving the care these clinicians can provide to
patients with substance use in the future. This is
critical, given that patients with substance use needs
may account for 55–70% of patients in the emer-
gency department.38
4. A systematic pathway was developed for all the
patients who underwent cardiothoracic surgery with
IVDU.
The future state includes assessing outcomes across
longer postintervention periods and within a larger
postintervention cohort. Furthermore, additional com-
ponents, such as medically enhanced residential treat-
ment, could be added into the intervention to improve
outcomes and reduce unnecessary resource needs.39
CONCLUSIONS
These results demonstrate that multidisciplinary in-
terventions and early involvement of pain manage-
ment and behavioral health/addiction medicine during
acute patient care for IE would improve patient
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SUPPLEMENTARY DATA
Supplementary data related to this article can be found
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Conflicts of Interest: The authors declare that they
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