1 00:00:02,980 --> 00:00:03,650 Hi, everyone. 2 00:00:03,659 --> 00:00:07,030 Welcome to Febrile, a cultured podcast about all things infectious disease. 3 00:00:08,059 --> 00:00:11,780 We use consult questions to dive into ID clinical reasoning, diagnostics, 4 00:00:11,780 --> 00:00:13,090 and antimicrobial management. 5 00:00:13,809 --> 00:00:16,300 I'm Sara Dong, your host and a MedPeds ID doc. 6 00:00:16,905 --> 00:00:19,155 Welcome to the next Febrile StAR episode. 7 00:00:19,225 --> 00:00:22,265 These will feature topics and authors from the CID Journal's 8 00:00:22,265 --> 00:00:23,465 State of the Art Reviews. 9 00:00:23,915 --> 00:00:27,275 You can listen to episode number 97 for a quick introduction from the 10 00:00:27,325 --> 00:00:31,204 editors of these reviews, and this is our second of four straight weeks of 11 00:00:31,514 --> 00:00:33,495 StAR episodes to kick off the series. 12 00:00:34,455 --> 00:00:36,674 All right, I'll introduce our guest stars today. 13 00:00:37,205 --> 00:00:37,544 Dr. 14 00:00:37,544 --> 00:00:41,294 Kinna Thakarar is an associate professor of medicine at Maine Health and 15 00:00:41,294 --> 00:00:42,985 Tufts University School of Medicine. 16 00:00:43,535 --> 00:00:47,045 She is an infectious diseases and addiction medicine physician. 17 00:00:47,614 --> 00:00:51,684 Her clinical and research interests include the ID and substance use syndemic, 18 00:00:52,155 --> 00:00:56,174 particularly harm reduction, shared decision making, and community based work. 19 00:00:56,315 --> 00:00:56,874 Hi there. 20 00:00:56,874 --> 00:01:00,165 This is Kinna Thakarar, and I am super excited to be here today. 21 00:01:01,065 --> 00:01:01,404 Dr. 22 00:01:01,404 --> 00:01:05,324 Ayesha Appa is an assistant professor of medicine at the University of California 23 00:01:05,354 --> 00:01:10,715 San Francisco, UCSF, where she completed ID and addiction fellowships in 2023. 24 00:01:11,505 --> 00:01:14,874 Her research and clinical priorities are on patient centered models of 25 00:01:14,874 --> 00:01:19,254 care for simultaneous treatment of addiction and infections including HIV. 26 00:01:19,845 --> 00:01:23,755 This is Ayesha Appa and similarly, psyched to join this crew. 27 00:01:24,315 --> 00:01:27,955 Chasity Tuell is a harm reductionist and serves as the Washington County 28 00:01:27,955 --> 00:01:30,065 Program Director for Maine Access Points. 29 00:01:30,660 --> 00:01:34,800 Maine Access Points is a harm reduction organization providing syringe access 30 00:01:34,800 --> 00:01:40,109 services, overdose prevention education, and naloxone distribution, peer support, 31 00:01:40,130 --> 00:01:42,019 and advocacy throughout rural Maine. 32 00:01:42,340 --> 00:01:43,600 This is Chasity Tuell. 33 00:01:43,600 --> 00:01:44,829 Thanks for having me today. 34 00:01:45,335 --> 00:01:47,045 Thank you guys so much for joining. 35 00:01:47,285 --> 00:01:51,385 Before we talk about the awesome cases today, we're gonna intro as 36 00:01:51,395 --> 00:01:53,515 everyone's favorite culture podcast. 37 00:01:53,625 --> 00:01:57,145 I would love to hear about a little piece of culture, basically something 38 00:01:57,154 --> 00:01:58,995 non medical that brings you joy. 39 00:01:59,234 --> 00:02:00,475 Mine is a bit random. 40 00:02:01,104 --> 00:02:05,015 So I grew up in the Philadelphia area and one thing that makes me 41 00:02:05,305 --> 00:02:10,345 really happy when I go home is Wawa coffee and a pretzel, a soft pretzel. 42 00:02:10,475 --> 00:02:12,475 I don't know if, if folks don't know what Wawa is. 43 00:02:12,484 --> 00:02:15,584 Some may refer to it as like a convenience store, but I like to 44 00:02:15,584 --> 00:02:17,244 joke that it's really a lifestyle. 45 00:02:18,934 --> 00:02:23,614 And one fun fact actually is that my parents, their first date was actually 46 00:02:23,614 --> 00:02:25,734 what is now a Wawa in West Philly. 47 00:02:26,024 --> 00:02:30,934 And so I think it's just hilariously like symbolic of our, our Wawa. 48 00:02:34,484 --> 00:02:35,554 That's beautiful. 49 00:02:35,954 --> 00:02:42,365 I could, I can go, my - I was trying to think about culture apart from the 50 00:02:42,365 --> 00:02:46,485 noise from my two toddlers that involves like Peppa Pig and things like this. 51 00:02:46,875 --> 00:02:52,214 Um, mine is not highbrow, but I was just on vacation and was a little late to this 52 00:02:52,225 --> 00:02:59,564 party but read Fourth Wing, which is this book that is this combination of Harry 53 00:02:59,564 --> 00:03:04,365 Potter and Hunger Games and also with a sort of like spicy romance element. 54 00:03:04,705 --> 00:03:06,345 I flew through that. 55 00:03:07,215 --> 00:03:09,645 So, good escapist rec for anyone. 56 00:03:10,254 --> 00:03:16,705 Right now one of my favorite joys has like really been junior high sports, 57 00:03:16,715 --> 00:03:22,345 which sounds so weird, but we're so invested in it at the moment, and 58 00:03:22,355 --> 00:03:27,234 being able to see how much the kids are changing and gaining confidence 59 00:03:27,235 --> 00:03:29,794 throughout the year has been so fun. 60 00:03:29,794 --> 00:03:32,945 And I've, realized I've turned into one of those people who just 61 00:03:32,945 --> 00:03:36,495 like randomly is looking at kids smiling so proud of them and then 62 00:03:36,495 --> 00:03:38,385 realizing like, I look like a freak. 63 00:03:40,605 --> 00:03:42,595 That's definitely it right now. 64 00:03:43,315 --> 00:03:44,225 Oh, I love it. 65 00:03:44,334 --> 00:03:46,474 Oh, thank you guys for sharing those. 66 00:03:46,969 --> 00:03:49,040 You know, I'm really excited to have you here. 67 00:03:49,070 --> 00:03:53,189 We're going to chat about your state of the art review, uh, which is entitled 68 00:03:53,189 --> 00:03:57,869 Frame Shift, Focusing on Harm Reduction and Shared Decision Making with People Who 69 00:03:57,869 --> 00:03:59,950 Use Drugs Hospitalized with Infections. 70 00:04:00,489 --> 00:04:04,670 I thought I would actually just ask if we could start with giving an introduction, 71 00:04:04,680 --> 00:04:07,799 the things that you were thinking about as you were crafting this article. 72 00:04:08,200 --> 00:04:11,579 Well, first I should give a shout out to the editorial team at CID 73 00:04:11,609 --> 00:04:13,940 for actually inviting us to do this state of the art review. 74 00:04:14,470 --> 00:04:16,230 You know, it was really meant to not just cover 75 00:04:16,810 --> 00:04:19,990 clinical presentation and management for people who use drugs, but 76 00:04:20,350 --> 00:04:23,460 they really wanted us to have like an intentional focus on shared 77 00:04:23,470 --> 00:04:27,129 decision making and harm reduction and approaches to reducing health 78 00:04:27,129 --> 00:04:29,269 inequities for people who use drugs. 79 00:04:29,320 --> 00:04:32,400 So, you know, with that, we, we consciously developed 80 00:04:32,400 --> 00:04:33,769 a multidisciplinary team. 81 00:04:33,769 --> 00:04:37,440 So, obviously, there's Chastity and Ayesha here today, but we also, 82 00:04:37,469 --> 00:04:42,820 our team included a PharmD, Jacinda Abdul-Mutakabbir, an addiction medicine 83 00:04:42,820 --> 00:04:47,830 nurse practitioner, Amelia Goff, and LCSW, Jess Brown, and then also actually 84 00:04:47,830 --> 00:04:51,200 my own mentor, Kathleen Fairfield, who's an expert in shared decision 85 00:04:51,200 --> 00:04:56,099 making, and of course, our amazing ID scientist colleague, Alysse Wurcel. 86 00:04:56,349 --> 00:05:00,599 What we did is we created some clinical cases to really illustrate a spectrum 87 00:05:00,629 --> 00:05:05,635 of fairly common scenarios, I think, and we provided viewpoints, especially 88 00:05:05,635 --> 00:05:07,605 where we don't have robust data. 89 00:05:07,905 --> 00:05:12,615 So, in the review, we tried to offer strategies for ID clinicians to use that 90 00:05:12,615 --> 00:05:16,144 really incorporates tenets of shared decision making and harm reduction. 91 00:05:16,605 --> 00:05:20,224 Before we dive into the cases, too, it's probably helpful to understand some of the 92 00:05:20,224 --> 00:05:22,504 barriers that people who use drugs face. 93 00:05:22,514 --> 00:05:26,205 So, I'm hoping, Chasity, maybe if you wanted to weigh in on this and just 94 00:05:26,245 --> 00:05:27,815 given your experiences in the field. 95 00:05:27,905 --> 00:05:34,854 Of course, so I am in very rural Maine and there's so much context in that. 96 00:05:35,255 --> 00:05:40,445 The landscape of the way the state is, so much is rural and we have to travel 97 00:05:40,465 --> 00:05:45,264 so far for anything and everything, not even just the length of travel. 98 00:05:45,445 --> 00:05:48,765 There's very limited, if any, public transportation. 99 00:05:49,145 --> 00:05:51,135 My area, we don't even have a taxi. 100 00:05:51,650 --> 00:05:55,470 There's a lot to think of there, so it makes it really challenging 101 00:05:55,480 --> 00:05:59,460 to get folks to appointments and anywhere they need to be. 102 00:05:59,960 --> 00:06:04,929 With that too, there's like a lot of the small town stigma that people face. 103 00:06:05,440 --> 00:06:10,809 I know that I have a lot of participants I encounter that won't go to the emergency 104 00:06:10,809 --> 00:06:15,100 room or won't go to local providers because someone they know that works 105 00:06:15,160 --> 00:06:19,559 there, or a family friend, or they had a rough couple of years in life, 106 00:06:19,559 --> 00:06:25,590 now they're excelling, but they're By their past in this really harmful way, 107 00:06:26,350 --> 00:06:31,229 a lot of times I think in policies and just decision making in general, 108 00:06:31,230 --> 00:06:33,550 those pieces don't get thought about. 109 00:06:33,569 --> 00:06:40,779 And it is such a huge piece of if people will choose or not choose to 110 00:06:40,790 --> 00:06:42,370 get the care that they really need. 111 00:06:42,570 --> 00:06:43,840 That's such good perspective. 112 00:06:43,870 --> 00:06:48,300 I think from like contextually, as I'm rooted in San Francisco 113 00:06:48,310 --> 00:06:51,830 on the other side of the country in a very urban environment. 114 00:06:51,860 --> 00:06:56,479 I don't often think about that with a small town perspective, though people 115 00:06:56,479 --> 00:06:59,830 who use drugs and are folks that we're interested in talking about today, what 116 00:06:59,830 --> 00:07:03,800 I hear is similar fear of discrimination. 117 00:07:04,015 --> 00:07:08,785 In that folks are using the same county hospitals or same couple of safety net 118 00:07:09,065 --> 00:07:14,415 institutions, and whether it's stigma and discrimination, really, that they've 119 00:07:14,415 --> 00:07:20,935 faced related to using drugs, or whether it's race, ethnicity, sexual orientation, 120 00:07:21,265 --> 00:07:27,455 sex or gender, approaching or, or really circumventing that takes a lot of courage 121 00:07:27,455 --> 00:07:30,645 on the part of people who use drugs when they've faced that in the past. 122 00:07:30,665 --> 00:07:35,204 And so that is, is one barrier is like even getting in the door and then in the 123 00:07:35,205 --> 00:07:40,004 line of sort of inequity and diagnosis and prevention and management of both 124 00:07:40,004 --> 00:07:42,134 infections and substance use disorders. 125 00:07:42,494 --> 00:07:47,115 It really like runs the gamut of, Implicit bias in prescribing antimicrobials 126 00:07:47,115 --> 00:07:50,195 or structurally racist policies that have sort of segregated our 127 00:07:50,455 --> 00:07:52,315 medications for opioid use disorder. 128 00:07:52,715 --> 00:07:56,180 There's just a lot of intersectionality really in creating these 129 00:07:56,200 --> 00:07:59,700 overlapping systems that can make it tough to get really good care. 130 00:08:00,140 --> 00:08:03,479 Also, maybe before we kick off with the cases, I'm sure most people know 131 00:08:03,480 --> 00:08:06,640 what harm reduction and shared decision making are, but maybe it would be 132 00:08:06,640 --> 00:08:08,820 helpful just to give a brief overview. 133 00:08:08,820 --> 00:08:12,815 Chasity, would you want to go over the definition of harm reduction. 134 00:08:13,015 --> 00:08:19,684 So harm reduction by definition, and you will see this in all policies now, 135 00:08:20,185 --> 00:08:25,234 is a set of practical strategies and ideas aimed at reducing the negative 136 00:08:25,234 --> 00:08:27,484 consequences associated with drug use. 137 00:08:28,084 --> 00:08:33,934 It was also built on a social justice movement for and by people who use drugs. 138 00:08:34,814 --> 00:08:40,039 In practice, that is autonomy, letting people have the right and 139 00:08:40,039 --> 00:08:43,289 the choice to what is best for them. 140 00:08:43,390 --> 00:08:44,120 Yeah, thanks for that. 141 00:08:44,120 --> 00:08:47,160 And I think, you know, from a clinical perspective, too, Ayesha, 142 00:08:47,180 --> 00:08:49,470 feel free to weigh in, but, you know, I think a harm reduction based 143 00:08:49,470 --> 00:08:52,159 approach to treating people who use drugs is really just so important. 144 00:08:52,339 --> 00:08:55,000 Just like what you said, you know, patient autonomy and making sure 145 00:08:55,000 --> 00:08:56,640 they're included in treatment plans. 146 00:08:57,160 --> 00:08:59,719 You know, that's where I think shared decision making comes in too. 147 00:08:59,719 --> 00:09:03,740 It's really a collaborative process where really, you know, the patients and their 148 00:09:03,740 --> 00:09:06,009 values are at the center of the decision. 149 00:09:06,009 --> 00:09:10,000 And so, I think we're just seeing more and more of that in treatment guidelines 150 00:09:10,000 --> 00:09:14,329 and especially where there's evidence that's still emerging or ambiguous. 151 00:09:14,439 --> 00:09:17,199 Harm reduction and, and shared decision making can be really 152 00:09:17,199 --> 00:09:18,829 helpful when we're caring for people. 153 00:09:19,115 --> 00:09:22,704 My simplistic take on it is that harm reduction is radical love. 154 00:09:22,715 --> 00:09:26,564 Like you're just like really trying to like see that person where they are and 155 00:09:26,564 --> 00:09:31,014 say like, I appreciate you for coming at whatever phase of change or not change. 156 00:09:31,014 --> 00:09:33,904 You are, you are just a human in front of me that I will 157 00:09:33,904 --> 00:09:35,354 help be as healthy as possible. 158 00:09:35,604 --> 00:09:36,054 All right. 159 00:09:36,154 --> 00:09:39,185 Are you guys ready to jump in with our example scenarios? 160 00:09:39,234 --> 00:09:40,124 Yeah, let's do it. 161 00:09:40,744 --> 00:09:41,194 Awesome. 162 00:09:42,405 --> 00:09:47,835 And all of these, I have to say as the reader of the paper that you've 163 00:09:47,845 --> 00:09:50,185 created, all of them feel familiar. 164 00:09:50,215 --> 00:09:54,934 I feel like all of these examples were things that I have participated 165 00:09:54,934 --> 00:09:56,695 in or, or been a part of. 166 00:09:57,245 --> 00:10:01,934 So our first scenario is we meet a 35 year old woman who is hospitalized 167 00:10:01,965 --> 00:10:04,135 for one week of fevers and rigors. 168 00:10:04,555 --> 00:10:07,895 She had taken a couple of days of doxycycline that she had received 169 00:10:07,905 --> 00:10:09,565 from a friend prior to coming in. 170 00:10:09,930 --> 00:10:14,069 On admission, her blood cultures from the ED demonstrate Streptococcus 171 00:10:14,099 --> 00:10:17,599 mitis, and then further workup identifies a dental infection. 172 00:10:18,889 --> 00:10:21,719 Ultimately, she has three days of bacteremia. 173 00:10:22,220 --> 00:10:26,730 Her co occurring conditions include anxiety, opioid use disorder, 174 00:10:26,730 --> 00:10:28,800 and a history of IV drug use. 175 00:10:29,530 --> 00:10:34,489 Her current treatment includes methadone and attending recovery group. 176 00:10:35,180 --> 00:10:37,650 She has no recent drug use or cravings. 177 00:10:38,049 --> 00:10:44,660 For a little bit more clinical info, the TTE and TEE were negative for vegetation. 178 00:10:45,000 --> 00:10:48,609 There's been no signs or symptoms of infective endocarditis. 179 00:10:48,610 --> 00:10:54,339 She successfully undergoes a dental extraction and during the admission, her 180 00:10:54,339 --> 00:10:59,129 home dose of methadone is continued and she attends her recovery group meetings 181 00:10:59,129 --> 00:11:00,919 virtually during the hospitalization. 182 00:11:01,439 --> 00:11:05,300 So now it's four days or so later, and she expresses to you 183 00:11:05,300 --> 00:11:07,290 her desire to be discharged home. 184 00:11:07,600 --> 00:11:12,140 She wants to be home with her children and complete the rest of the course 185 00:11:12,150 --> 00:11:15,649 with IV antibiotics because I didn't mention this, but she had been unable 186 00:11:15,649 --> 00:11:19,060 to tolerate some of the oral antibiotics that were tried during her admission. 187 00:11:19,565 --> 00:11:23,455 You know, she tells you, I feel like I can safely care for my PICC line at home. 188 00:11:23,865 --> 00:11:27,775 She's eligible for home health services and, and shares that she understands 189 00:11:27,784 --> 00:11:31,465 the risks of incomplete treatment and has really good family support. 190 00:11:31,945 --> 00:11:34,505 So how would you guys approach this scenario? 191 00:11:34,655 --> 00:11:34,935 Let's see. 192 00:11:34,935 --> 00:11:38,124 Well, Chasity, would you want to weigh in maybe a little bit before we dive 193 00:11:38,124 --> 00:11:41,475 into the management and maybe just thinking about potential barriers 194 00:11:41,635 --> 00:11:45,615 she may have faced in coming to the hospital that could have impacted her 195 00:11:45,615 --> 00:11:47,564 care, or things we could do better. 196 00:11:48,474 --> 00:11:50,545 Well, as it was asked, who wants to take this? 197 00:11:50,545 --> 00:11:53,324 I was thinking, I'm not a doctor, these questions aren't for me. 198 00:11:53,634 --> 00:11:57,685 But I can see myself on the other side of it, like as the patient, 199 00:11:57,704 --> 00:11:58,104 Yes. 200 00:11:58,490 --> 00:11:59,349 So important. 201 00:11:59,459 --> 00:12:04,630 There's so many pieces like, and I think as a mother also that is 202 00:12:04,630 --> 00:12:09,520 relevant, like we put off our own care to take care of our family. 203 00:12:09,690 --> 00:12:13,180 So that's adding just another level of barrier to this. 204 00:12:13,259 --> 00:12:18,550 So it's difficult to try and go take care of yourself, 205 00:12:18,579 --> 00:12:21,109 especially if you have children. 206 00:12:21,485 --> 00:12:26,005 And if there's been any negative experiences, and I think at some point, 207 00:12:26,055 --> 00:12:31,474 everybody has had a negative health care experience, even very minor, all 208 00:12:31,474 --> 00:12:37,500 of that weighs on us being on methadone, that's already so high barrier for 209 00:12:37,500 --> 00:12:43,669 people in any ways, because there's so much asked of them to go daily, multiple 210 00:12:43,669 --> 00:12:48,019 times a week, whatever it is, it's so restrictive and it takes so much time 211 00:12:48,020 --> 00:12:52,930 and takes away from our family, our jobs, and all of our responsibilities, 212 00:12:53,579 --> 00:12:58,500 it is really difficult to get yourself to the point to go to the hospital 213 00:12:58,500 --> 00:13:01,070 and have to spend so much time there. 214 00:13:01,550 --> 00:13:06,180 Other people that haven't lived through any of this think 215 00:13:06,180 --> 00:13:07,630 that just sounds ridiculous. 216 00:13:07,680 --> 00:13:08,079 Like. 217 00:13:08,490 --> 00:13:09,990 Well, you have to take care of yourself. 218 00:13:09,990 --> 00:13:13,500 And it's like, yeah, we do, but there's also all of these other 219 00:13:13,500 --> 00:13:15,510 pieces people aren't thinking about. 220 00:13:15,790 --> 00:13:18,900 I know it's very easy to dole out the advice and then think about like, oh, yes, 221 00:13:18,930 --> 00:13:20,600 how am I getting to my own appointment? 222 00:13:20,600 --> 00:13:21,960 I can barely hold this together. 223 00:13:21,970 --> 00:13:25,649 Like, how are we expecting this person with dependence and a daily need 224 00:13:25,650 --> 00:13:27,210 to go to a clinic to do all this? 225 00:13:27,790 --> 00:13:31,600 Getting back to your question, Sara, of like, of how do you manage this scenario? 226 00:13:31,600 --> 00:13:32,680 Or how do you approach this?? 227 00:13:33,090 --> 00:13:38,915 If there's one thing that you remember from this case, I'd want it to be that 228 00:13:38,915 --> 00:13:44,165 substance use is not a contraindication to discharging people home with OPAT. 229 00:13:44,865 --> 00:13:49,364 It's really easy for us to look at the chart and say like history of IDU 230 00:13:50,005 --> 00:13:55,605 and have that color this person's care going forward in perpetuity, but being 231 00:13:55,605 --> 00:13:59,395 a part of this article was a really nice opportunity to dive into this 232 00:13:59,925 --> 00:14:04,515 grey area and really help people work with their patients to make a decision 233 00:14:04,565 --> 00:14:06,635 about the best treatment strategies. 234 00:14:07,365 --> 00:14:11,295 In this case, this person is someone with opioid use disorder in remission 235 00:14:11,305 --> 00:14:15,684 who's on methadone, who hasn't described recent injection drug use. 236 00:14:15,685 --> 00:14:21,555 And so it is someone in whom I'm not so worried about the risks of, 237 00:14:21,555 --> 00:14:25,805 say, secondary bacteremia related to injecting through a PICC. 238 00:14:26,145 --> 00:14:32,255 I am really not worried about life chaos that might be associated with some people 239 00:14:32,265 --> 00:14:36,445 who are using and, say, experiencing homelessness or using stimulants, etc. 240 00:14:36,695 --> 00:14:38,984 This is somebody who's housed with kids. 241 00:14:39,315 --> 00:14:40,875 She's getting a lot of stuff done for her. 242 00:14:41,125 --> 00:14:46,965 And so, broadly, consider OPAT for people using substances, and then be specific 243 00:14:47,244 --> 00:14:52,225 about what, what the concern might be if there is one related to substance use. 244 00:14:52,405 --> 00:14:55,624 We go into some of these data in our article. 245 00:14:55,694 --> 00:14:59,745 Joji Suzuki and colleagues from Partners did a really nice review published 246 00:14:59,745 --> 00:15:05,435 in OFID looking at essentially the data quantifying adverse events or 247 00:15:05,435 --> 00:15:09,425 successful completion of OPAT in people injecting drugs or using drugs. 248 00:15:09,645 --> 00:15:13,165 And so I'd refer to that in our section of that article if you're 249 00:15:13,225 --> 00:15:14,514 feeling the need to be bolstered. 250 00:15:14,615 --> 00:15:18,375 The other thing too I sometimes bring up with folks if you do get pushback 251 00:15:18,375 --> 00:15:21,295 is like if they're being denied OPAT. 252 00:15:21,295 --> 00:15:24,355 I mean, that It could be considered, you know, a violation of the Americans 253 00:15:24,355 --> 00:15:27,935 with Disabilities Act or the ADA, and so, I mean, I'm not a lawyer, 254 00:15:27,935 --> 00:15:31,164 obviously, but what is recommended is you, there are ways to, you know, 255 00:15:31,164 --> 00:15:36,195 file a report, and we just, like, have to advocate in situations like this. 256 00:15:36,284 --> 00:15:38,785 So, but I totally agree with everything that s been said. 257 00:15:39,205 --> 00:15:42,305 One other thing in terms of management is, you know, how to incorporate 258 00:15:42,305 --> 00:15:44,615 shared decision making for this case. 259 00:15:44,615 --> 00:15:48,335 You know, I think we know, we all know that these prolonged hospitalizations 260 00:15:48,355 --> 00:15:52,625 can be really harmful for patients and some clinicians, though, may perceive 261 00:15:52,635 --> 00:15:56,189 that being in the hospital, you know, it's a protective environment, but the 262 00:15:56,189 --> 00:15:59,349 reality is, you know, people they want to use drugs are going to use it, you 263 00:15:59,349 --> 00:16:02,680 know, even if it's in the hospital and like Chasity said, they, you know, folks 264 00:16:02,680 --> 00:16:05,079 have families or job responsibilities. 265 00:16:05,079 --> 00:16:08,170 And so they may not want to be there for that long. 266 00:16:08,180 --> 00:16:11,209 And so they can also, you know, have stigmatizing encounters 267 00:16:11,209 --> 00:16:12,650 or get nosocomial infections. 268 00:16:12,670 --> 00:16:17,640 So I think it's really on us to really, you know, meet with each patient and 269 00:16:17,680 --> 00:16:21,520 everyone's going to have different values and preferences and goals and really try 270 00:16:21,520 --> 00:16:23,300 to incorporate shared decision making. 271 00:16:23,530 --> 00:16:25,069 You know, one thing I've heard from colleagues. 272 00:16:25,069 --> 00:16:26,980 I was like, oh, it's it's so time consuming. 273 00:16:26,980 --> 00:16:30,550 And so, you know, we have borrowed from the palliative care field where they 274 00:16:30,550 --> 00:16:34,910 use the serious illness conversation guide, which is really considered 275 00:16:34,910 --> 00:16:36,550 best practices in palliative care. 276 00:16:36,550 --> 00:16:39,380 And so there's not much data in people who use drugs. 277 00:16:39,390 --> 00:16:42,680 So in Maine, we actually ended up building on shared decision making 278 00:16:42,689 --> 00:16:46,449 and this conversation guide to develop and implement a guide that 279 00:16:46,450 --> 00:16:48,329 was specific to people who use drugs. 280 00:16:48,340 --> 00:16:50,110 And I mean, it was pretty well received. 281 00:16:50,140 --> 00:16:51,520 It was a small pilot study. 282 00:16:51,520 --> 00:16:55,870 Obviously we need more data and more research, but it was really promising 283 00:16:55,880 --> 00:17:01,675 and it was a way to really incorporate patient preferences, discussing treatment 284 00:17:01,685 --> 00:17:06,055 options and tradeoffs for different approaches, and then just, you know, 285 00:17:06,065 --> 00:17:10,025 closing the conversation, documenting it, and communicating with physicians. 286 00:17:10,055 --> 00:17:14,904 So in this particular case, though, you know, we recommended in the review 287 00:17:15,285 --> 00:17:19,084 to have this, you know, structured conversation, understanding this patient's 288 00:17:19,555 --> 00:17:25,540 preferences, and you know, she has a good understanding of her infection and 289 00:17:25,540 --> 00:17:29,550 the different treatment options, also has stable housing, family support. 290 00:17:29,580 --> 00:17:33,870 So, we recommended that the primary team consider discharging her home with OPAT, 291 00:17:34,679 --> 00:17:38,530 you know, the methadone environment is pretty restrictive in terms of 292 00:17:38,530 --> 00:17:40,149 the regulatory environment right now. 293 00:17:40,149 --> 00:17:44,400 And so, if this patient has to go to the methadone clinic every day, 294 00:17:44,410 --> 00:17:48,300 you know, considering something like ceftriaxone once a day, just so that 295 00:17:48,300 --> 00:17:51,390 doesn't interfere with her going to and from the methadone clinic. 296 00:17:51,525 --> 00:17:52,095 Totally. 297 00:17:52,175 --> 00:17:56,945 I was going to say the exact same thing as like that concrete pearl for ID providers. 298 00:17:56,965 --> 00:17:59,255 It's like know your patient's lives. 299 00:17:59,255 --> 00:18:02,964 And again, this applies to everything, not just people who use, but, but, you 300 00:18:02,964 --> 00:18:04,724 know, know their lives and what fits in. 301 00:18:04,745 --> 00:18:09,150 I think OPAT providers are really good at trying to select antibiotics that 302 00:18:09,150 --> 00:18:13,310 will be least burdensome, and that's like particularly true, I think, with 303 00:18:13,450 --> 00:18:14,820 thinking about how methadone fits in. 304 00:18:15,280 --> 00:18:16,050 Excellent. 305 00:18:16,139 --> 00:18:16,639 Okay. 306 00:18:16,669 --> 00:18:19,090 So we're going to go on to our next scenario. 307 00:18:19,549 --> 00:18:23,959 This time we meet a 44 year old male who injects fentanyl and is 308 00:18:23,959 --> 00:18:27,459 experiencing homelessness after recently being released from jail. 309 00:18:27,919 --> 00:18:32,010 He's currently hospitalized with MRSA mitral valve endocarditis. 310 00:18:32,540 --> 00:18:33,519 So there's a 0. 311 00:18:33,520 --> 00:18:39,209 5 centimeter mitral valve vegetation noted on TEE with no other abnormalities. 312 00:18:39,770 --> 00:18:43,810 So the multidisciplinary endocarditis team recommends medical management. 313 00:18:44,560 --> 00:18:49,259 The inpatient addiction consult service diagnosed him with opioid use disorder 314 00:18:49,699 --> 00:18:53,389 and the patient identifies his goal as abstaining from further fentanyl use. 315 00:18:53,850 --> 00:18:58,260 In hospital, they initiate methadone with a plan to up titrate while he is there. 316 00:18:58,910 --> 00:19:01,750 He meets with a licensed clinical social worker to help 317 00:19:01,750 --> 00:19:03,650 facilitate housing applications. 318 00:19:04,390 --> 00:19:07,730 And after about four weeks in the hospital, the patient feels that 319 00:19:07,730 --> 00:19:09,820 he is at a stable methadone dose. 320 00:19:10,320 --> 00:19:12,799 He is not experiencing significant cravings. 321 00:19:13,270 --> 00:19:17,080 And though he has not yet secured housing, he starts to express 322 00:19:17,080 --> 00:19:18,970 his desire to leave the hospital. 323 00:19:19,439 --> 00:19:23,289 He does not want to be discharged with a PICC, but does want his infection 324 00:19:23,290 --> 00:19:25,000 to be treated the best that it can. 325 00:19:25,439 --> 00:19:29,560 And the other additional piece of information is that he does have a sulfa 326 00:19:29,560 --> 00:19:34,439 allergy with a history of anaphylaxis and his medication list includes sertraline. 327 00:19:35,389 --> 00:19:36,169 What do you guys think? 328 00:19:36,169 --> 00:19:37,520 How should we approach this case? 329 00:19:38,029 --> 00:19:38,649 Thanks, Sara. 330 00:19:39,050 --> 00:19:45,950 I am, in thinking about this case again, just feeling really thankful that we 331 00:19:45,950 --> 00:19:49,979 are where we are today, even if we have a long way to go, and like, really 332 00:19:49,980 --> 00:19:55,130 delivering equitable care to people who use drugs, you know, in this case, we are 333 00:19:55,365 --> 00:19:59,105 taking care of somebody who is admitted to a hospital with an addiction consult 334 00:19:59,105 --> 00:20:03,715 service, which may not be the standard for every hospital in the country. 335 00:20:03,715 --> 00:20:09,425 And again, this is specific, but this is a very different clinical stem than, let's 336 00:20:09,425 --> 00:20:15,265 say, I think patients that I was seeing in residency not so, so long ago in 2015. 337 00:20:15,625 --> 00:20:20,595 There's this implicit understanding in the stem you presented that treating 338 00:20:20,635 --> 00:20:25,704 addiction should be standard of care when managing infectious complications of drug 339 00:20:25,704 --> 00:20:30,184 use, or when really just like seeing a patient with a substance use disorder at 340 00:20:30,405 --> 00:20:35,444 a touch point that is the hospitalization, thinking about, you know, what can we do 341 00:20:35,444 --> 00:20:40,750 in a wraparound way to treat this person's addition, how can we advance their care 342 00:20:40,940 --> 00:20:45,669 and really treat the root cause of this infection and prevent further infections 343 00:20:45,690 --> 00:20:48,200 is the standard, which is fantastic. 344 00:20:48,690 --> 00:20:52,999 Generally, he's gotten a diagnosis of opioid use disorder, gotten 345 00:20:52,999 --> 00:20:57,659 started on methadone, which is fantastic and is getting uptitrated. 346 00:20:58,070 --> 00:21:01,879 When I see that he's at a stable methadone dose after four weeks in 347 00:21:01,879 --> 00:21:03,950 the hospital, that's another huge win. 348 00:21:04,180 --> 00:21:07,869 This is somebody who stayed in the hospital or, you know, in a supervised 349 00:21:07,870 --> 00:21:13,759 setting for a month whose dose was up titrated effectively, which is often, 350 00:21:13,900 --> 00:21:18,330 you know, we're often seeing folks leave potentially in the setting of meds for 351 00:21:18,330 --> 00:21:23,315 opioid use disorder not even being started or offered, or doses not being adequate 352 00:21:23,335 --> 00:21:28,005 enough to address either withdrawal or cravings and really get to a stable dose. 353 00:21:28,555 --> 00:21:33,145 Those are wins in the stem and things that I encourage anybody listening 354 00:21:33,165 --> 00:21:37,004 to, to make sure are in place in your medical settings that you have 355 00:21:37,004 --> 00:21:42,925 a way of offering buprenorphine and methadone for opioid use disorder and 356 00:21:42,925 --> 00:21:46,345 thinking carefully about what your, what your resources are for stimulant 357 00:21:46,345 --> 00:21:50,725 use disorder and all use disorders that may be related to someone's infection. 358 00:21:51,335 --> 00:21:54,914 The last thing I'll just say about that broadly is I know that the access 359 00:21:54,915 --> 00:21:59,164 to methadone is really fragmented and different across the country. 360 00:21:59,164 --> 00:22:03,175 And so there may be, I think there are opportunities for advocacy on the 361 00:22:03,480 --> 00:22:07,510 individual systems level, or like medical, medical center level, you know, up 362 00:22:07,510 --> 00:22:09,380 through state and federal levels here. 363 00:22:09,780 --> 00:22:13,549 Kinna, maybe I'll ask you your approach to, we have some specific 364 00:22:13,549 --> 00:22:17,770 information about where he is in his course of endocarditis treatment, 365 00:22:18,030 --> 00:22:22,564 and I'm curious how you approach the antibiotic prescribing options. 366 00:22:22,715 --> 00:22:27,334 This also gets back to the, you know, conversation guide and making sure that 367 00:22:27,695 --> 00:22:33,584 we offer any quote unquote non traditional options, so that could include long acting 368 00:22:33,594 --> 00:22:36,194 antibiotic infusions and oral antibiotics. 369 00:22:36,205 --> 00:22:39,225 So, you know, for this case, he's made it, you know, pretty clear he doesn't 370 00:22:39,225 --> 00:22:43,910 want to PICC but we could discuss dalbavancin or oral antibiotics. 371 00:22:44,410 --> 00:22:47,240 In the interest of time, I'm not going to go through all of the options, 372 00:22:47,270 --> 00:22:48,590 but you can read in the review. 373 00:22:48,590 --> 00:22:50,650 But also, you know, I think it was Dr. 374 00:22:50,650 --> 00:22:52,270 Baddour and actually Dr. 375 00:22:52,270 --> 00:22:53,180 Wurcel as well. 376 00:22:53,190 --> 00:22:57,475 They have a really great paper and It was published in Circulation, I believe, in 377 00:22:57,475 --> 00:23:02,485 2022 that really summarizes very well, sort of, going through the feasibility 378 00:23:02,495 --> 00:23:06,284 of these different options for people who use drugs with endocarditis. 379 00:23:06,455 --> 00:23:08,305 So, I definitely recommend reading that. 380 00:23:08,335 --> 00:23:12,504 But I think just generally, you know, thinking about each option, you know, for 381 00:23:12,504 --> 00:23:17,524 this patient, do they have transportation to get to a center where he can get a 382 00:23:17,524 --> 00:23:19,995 long acting injectable like dalbavancin? 383 00:23:20,335 --> 00:23:24,865 Obviously, you know, there's still RCTs going on to look at dalbavancin 384 00:23:24,885 --> 00:23:28,095 in infective endocarditis, but there's really promising data. 385 00:23:28,565 --> 00:23:33,365 Also talking about oral antimicrobials in this case would be relevant and 386 00:23:33,365 --> 00:23:36,505 we should definitely do that for this patient just knowing his goals. 387 00:23:36,865 --> 00:23:39,955 At the end of the day, thinking about structural drivers of health 388 00:23:39,955 --> 00:23:43,085 and the feasibility of treatment options should be prioritized. 389 00:23:43,085 --> 00:23:46,745 And I think the other big discussion point that we had in the paper is 390 00:23:46,755 --> 00:23:51,085 also making sure that we prioritize treatment for substance use, looking 391 00:23:51,085 --> 00:23:56,025 at any drug drug interactions, because we know that there are certain touch 392 00:23:56,025 --> 00:24:00,285 points where people are at very high risk for overdose, and sadly, discharge 393 00:24:00,285 --> 00:24:01,604 from the hospital is one of them. 394 00:24:01,604 --> 00:24:04,665 And so, if patients want to go on treatment, I think we need to 395 00:24:04,665 --> 00:24:08,145 do our best to, like, make that transition as smooth as possible. 396 00:24:08,185 --> 00:24:12,504 So, just as like a concrete example here for this case, thinking about the 397 00:24:12,504 --> 00:24:16,335 POET trial, for example, they looked at linezolid and rifampin, but we 398 00:24:16,335 --> 00:24:19,665 know that rifampin can markedly reduce methadone levels and may, you know, 399 00:24:19,665 --> 00:24:24,455 reduce buprenorphine levels, and so would we want to perhaps consider rifabutin 400 00:24:24,465 --> 00:24:28,855 instead of rifampin or just, you know, go with linezolid monotherapy knowing that 401 00:24:28,855 --> 00:24:30,794 there may be, you know, limited data. 402 00:24:30,865 --> 00:24:35,284 So I think it's just talking about these tradeoffs and options openly 403 00:24:35,284 --> 00:24:40,660 with patients is best practice, but And it's probably obvious, but I think 404 00:24:40,660 --> 00:24:44,190 it's important to also say that we should, we recommend, again, stopping 405 00:24:44,190 --> 00:24:48,050 substance use treatment like methadone and buprenorphine just to accommodate, 406 00:24:48,070 --> 00:24:49,609 you know, antimicrobial options. 407 00:24:49,780 --> 00:24:54,650 The other unique thing about this case is him being in a rural state, right? 408 00:24:54,669 --> 00:24:58,580 So I think we know that rural areas are really disproportionately burdened 409 00:24:58,590 --> 00:25:03,310 by substance use and drug overdose deaths, and people have limited 410 00:25:03,320 --> 00:25:05,070 access to certain types of care. 411 00:25:05,070 --> 00:25:07,620 So, I don't know, Chasity, if you want to weigh in here a little bit for this 412 00:25:07,620 --> 00:25:10,969 case too, because since you work in one of the most rural counties in the U. 413 00:25:10,969 --> 00:25:11,159 S. 414 00:25:12,460 --> 00:25:17,339 Yeah, I was looking at it and thinking about the fact that they 415 00:25:17,509 --> 00:25:21,809 still haven't secured housing and they're in rural Maine. 416 00:25:21,999 --> 00:25:24,730 There's so many layers to that. 417 00:25:25,390 --> 00:25:30,030 They're going to need to get to their clinic, and since they're a new patient, 418 00:25:30,080 --> 00:25:31,580 they're going to have to go often. 419 00:25:32,430 --> 00:25:35,879 But they also don't know where they're sleeping, so adding any 420 00:25:35,880 --> 00:25:42,070 restrictions on treatment is going to make everything in their life harder. 421 00:25:42,539 --> 00:25:47,970 We have to travel really far, and we don't have shelters, so we do 422 00:25:47,990 --> 00:25:54,629 a lot of couch surfing, and we don't even have, um, encampments 423 00:25:54,629 --> 00:25:55,940 like you have in bigger cities. 424 00:25:55,960 --> 00:26:01,790 So, as terrible as that is, there's no sense of community for the people 425 00:26:01,790 --> 00:26:03,909 experiencing homelessness in rural Maine. 426 00:26:03,939 --> 00:26:05,340 So, it's really isolating. 427 00:26:05,370 --> 00:26:10,259 So, I think in cases like this, just being able to connect folks to people 428 00:26:10,260 --> 00:26:15,460 that are already embedded in the community is really, really important. 429 00:26:15,810 --> 00:26:20,635 And then they have another touch point for anything that they need. 430 00:26:21,095 --> 00:26:22,325 We're, we're small town Maine. 431 00:26:22,325 --> 00:26:25,585 If we don't have an answer, we know who has the answer. 432 00:26:25,665 --> 00:26:26,315 I love that. 433 00:26:27,615 --> 00:26:33,675 One other thing that I'll just add around the drug drug interaction point. 434 00:26:33,815 --> 00:26:34,504 I agree. 435 00:26:34,554 --> 00:26:39,534 I hope most people aren't in a cavalier fashion stopping methadone 436 00:26:39,564 --> 00:26:43,465 or bupe, but I've had many a good conversation with folks about 437 00:26:43,465 --> 00:26:44,845 like, you know, the rifampin is 438 00:26:45,235 --> 00:26:45,985 important. 439 00:26:46,014 --> 00:26:47,865 And that's what's evidence based. 440 00:26:47,865 --> 00:26:52,055 Our data for rifabutin are poor or our data for monotherapy or some of these 441 00:26:52,055 --> 00:26:53,725 alternative options are not there. 442 00:26:54,085 --> 00:26:57,014 And, and so like, can't we just increase the methadone? 443 00:26:57,685 --> 00:27:02,105 Of course there are many options on the table, but disrupting someone's 444 00:27:02,115 --> 00:27:07,605 stable methadone dose with PK that's like really unreliable, like that 445 00:27:07,605 --> 00:27:11,635 you cannot really predict when, if any, and to what degree someone's 446 00:27:11,784 --> 00:27:14,135 effect will, will be felt from that. 447 00:27:15,065 --> 00:27:18,165 Induction via rifampin is incredibly destabilizing. 448 00:27:18,175 --> 00:27:20,765 I've seen a number of patients who've been on RIF and didn't really 449 00:27:20,765 --> 00:27:24,805 understand what was going to happen and returned to use and again, 450 00:27:24,815 --> 00:27:26,185 really destabilizing in their lives. 451 00:27:26,415 --> 00:27:31,500 So would really prioritize maintaining that methadone whether it's drug drug 452 00:27:31,500 --> 00:27:35,550 interaction wise, or just the act of, of, of going, um, and, and having a 453 00:27:35,550 --> 00:27:38,250 conversation with your patients, with your addiction medicine colleagues, if, 454 00:27:38,600 --> 00:27:40,990 if there's questions to, to get at that. 455 00:27:41,040 --> 00:27:41,490 Great. 456 00:27:42,030 --> 00:27:42,589 All right. 457 00:27:42,649 --> 00:27:45,790 And I'll move us forward to our next scenario. 458 00:27:46,199 --> 00:27:49,439 This time we meet a 35 year old transgender woman who is 459 00:27:49,439 --> 00:27:50,549 experiencing homelessness. 460 00:27:51,609 --> 00:27:56,550 She is admitted with pan susceptible Serratia bacteremia in the setting of 461 00:27:56,580 --> 00:27:58,699 IV fentanyl and methamphetamine use. 462 00:27:59,274 --> 00:28:03,955 She has been injecting drugs with non sterile water, shares needles, given there 463 00:28:03,955 --> 00:28:08,014 is no access to a syringe service program in her primarily Black neighborhood. 464 00:28:08,584 --> 00:28:11,745 The patient occasionally engages in primary care through 465 00:28:11,764 --> 00:28:13,324 a local mobile health unit. 466 00:28:13,614 --> 00:28:16,894 She is not currently interested in outpatient substance 467 00:28:16,965 --> 00:28:18,544 use disorder treatment. 468 00:28:18,545 --> 00:28:23,915 Her bacteremia is initially treated with cefepime, and opioid withdrawal 469 00:28:23,915 --> 00:28:25,895 is treated with short acting opioids. 470 00:28:26,735 --> 00:28:30,784 Two days into her hospitalization, She decides to leave the hospital. 471 00:28:31,245 --> 00:28:36,795 It's midnight and you get a call to ask for help on, on how to move forward. 472 00:28:36,845 --> 00:28:40,654 So I will say that the, you know, goal of having structured conversations 473 00:28:40,654 --> 00:28:43,734 about treatment options and their trade offs is to hopefully minimize 474 00:28:43,765 --> 00:28:47,365 unplanned discharges like this and, you know, talking about oral antibiotic 475 00:28:47,365 --> 00:28:51,495 options and, um, documenting them and putting it in the chart so that cross 476 00:28:51,495 --> 00:28:56,385 covering teams can use that information if an unplanned discharge happens, 477 00:28:56,834 --> 00:28:58,485 you know, that's the ideal situation. 478 00:28:58,485 --> 00:29:02,355 But that being said, you know, unplanned discharges can happen and oftentimes 479 00:29:02,355 --> 00:29:06,524 it feels like it's always at midnight or overnight and there is a really 480 00:29:06,554 --> 00:29:10,070 great, it was a single site study, I think by Laura Marks and colleagues, 481 00:29:10,360 --> 00:29:13,670 where they showed that at least offering oral antibiotics compared to 482 00:29:13,670 --> 00:29:16,040 no antibiotics had better outcomes. 483 00:29:16,060 --> 00:29:19,600 So, I think at the end of the day, the take home point here is like, there's 484 00:29:19,610 --> 00:29:23,900 always something we can do for patients on discharge, whether that's, you know, 485 00:29:23,909 --> 00:29:27,620 oral antibiotics, naloxone, or, you know, something I always talk about 486 00:29:27,630 --> 00:29:31,110 with trainees is just contact us and we can still get, you know, expedited 487 00:29:31,140 --> 00:29:33,579 telehealth or follow up ID visits. 488 00:29:33,610 --> 00:29:36,535 In Maine, we work very closely with our homeless health partners. 489 00:29:36,545 --> 00:29:40,735 So, we'll just message them afterwards to try to arrange follow up and in 490 00:29:40,735 --> 00:29:44,140 Laura Marks' study, they looked at how those follow up visits were really 491 00:29:44,140 --> 00:29:49,040 helpful for discussing PEP or PrEP and harm reduction counseling, making sure 492 00:29:49,040 --> 00:29:52,369 they actually got their antibiotics if they were discharged or, you know, 493 00:29:52,370 --> 00:29:54,240 whatever other help they needed. 494 00:29:54,540 --> 00:29:58,189 Just recognizing that, especially for this case, there are still things that 495 00:29:58,190 --> 00:30:02,229 we can do to really, you know, optimize this patient's health and safety. 496 00:30:02,229 --> 00:30:06,295 So, the hospital really can be an opportunity for, infectious 497 00:30:06,355 --> 00:30:08,015 disease screening and prevention. 498 00:30:08,065 --> 00:30:12,685 So when this patient is hospitalized, it'd be great to go through, like, 499 00:30:12,775 --> 00:30:15,175 how does, how is she using drugs? 500 00:30:15,285 --> 00:30:19,115 Um, does she have access to syringe services programs, naloxone, and 501 00:30:19,474 --> 00:30:24,394 talking about screening for STIs, PEP and PrEP, all the things, and, 502 00:30:24,404 --> 00:30:28,375 you know, seeing if she has access to local harm reduction organizations. 503 00:30:28,395 --> 00:30:32,285 And the other part of this, I think, too, is making sure folks, you know, offering 504 00:30:32,285 --> 00:30:39,000 screening for HIV, other STIs, including extragenital testing, CDC really says, 505 00:30:39,000 --> 00:30:42,440 you know, annual testing, but I think in this review we said at least every 506 00:30:42,440 --> 00:30:45,239 three months or even more frequently depending on how people are using, 507 00:30:45,239 --> 00:30:47,190 right, if they're sharing equipment. 508 00:30:47,600 --> 00:30:50,019 Maybe they need, you know, more frequent screening. 509 00:30:50,080 --> 00:30:54,669 Also, for this patient early on, we tried to offer her vaccines. 510 00:30:54,759 --> 00:30:57,170 Here in Maine, actually, we're seeing, we have some of the highest 511 00:30:57,170 --> 00:31:01,620 rates of acute Hep B and are having clusters of Hep A infections now. 512 00:31:01,670 --> 00:31:06,340 So, offering, you know, Hep A and B vaccines, Tdap, Prevnar, COVID, all 513 00:31:06,340 --> 00:31:11,349 the things and, you know, we know that even 1 dose of hepatitis vaccine 514 00:31:11,349 --> 00:31:14,439 can provide some coverage and you don't have to wait for serologies. 515 00:31:14,450 --> 00:31:19,360 That's per CDC guidelines and so trying to offer all of these things as 516 00:31:19,360 --> 00:31:22,580 early on as possible so that if they do leave early, you know, there are 517 00:31:22,580 --> 00:31:24,980 some preventive strategies in place. 518 00:31:25,955 --> 00:31:29,065 I think this can be like a lot, somewhat overwhelming to think about. 519 00:31:29,065 --> 00:31:31,955 So I think like, if you have a way to do this systematically, 520 00:31:31,955 --> 00:31:33,405 wherever you practice, it's helpful. 521 00:31:33,405 --> 00:31:35,875 You know, like in Maine, we have a little checklist in EPIC. 522 00:31:35,875 --> 00:31:39,604 We have a smart phrase that we use and, you know, folks have done some studies 523 00:31:39,605 --> 00:31:44,615 on bundled interventions and toolkits and it is feasible, I think, to, to do this. 524 00:31:45,055 --> 00:31:45,285 Yeah. 525 00:31:45,295 --> 00:31:50,445 I really just want to underscore how validating, or I think like 526 00:31:50,475 --> 00:31:55,675 offering those, I was going to say harm reduction screenings, but it's 527 00:31:55,685 --> 00:31:57,775 really just general health screenings. 528 00:31:57,775 --> 00:32:02,615 And again, that sort of no wrong door opportunity to offer screening and 529 00:32:02,615 --> 00:32:06,955 testing for things that, you know, you may have done in a clinic setting, but 530 00:32:06,955 --> 00:32:10,515 again, like someone's here accessing services, like how can we offer it? 531 00:32:10,645 --> 00:32:14,505 It can be just a beautiful start to a conversation with someone that feels 532 00:32:15,095 --> 00:32:18,585 It's very validating, like, ah, yes, you're not going to push treatment 533 00:32:18,595 --> 00:32:21,165 on me because that's not what I'm interested in, but you're going to try 534 00:32:21,165 --> 00:32:24,815 to optimize my health and know that I care about my health regardless. 535 00:32:25,375 --> 00:32:29,304 It's really easy when we've gone through medical training that's like heavily 536 00:32:29,304 --> 00:32:32,194 inpatient and you're doing these like blocks of time in the hospital and 537 00:32:32,194 --> 00:32:35,345 then maybe you have like little smidges in between of clinic, like you really 538 00:32:35,355 --> 00:32:39,185 think about life as like the hospital and then the clinic, but patients are 539 00:32:39,185 --> 00:32:40,785 not experiencing life that way, right? 540 00:32:40,785 --> 00:32:43,724 Like they're, they're going in and out and this, like this is their life and 541 00:32:43,724 --> 00:32:47,300 their health and they're contending with doctors in different places, but 542 00:32:47,340 --> 00:32:52,780 it's really the infection or the XYZ cause of hospitalization, not the care 543 00:32:52,870 --> 00:32:55,229 setting that they're orienting around. 544 00:32:55,259 --> 00:32:58,689 And so it's really artificial that we orient ourselves that way. 545 00:32:59,139 --> 00:33:03,080 If we want good outcomes in, in people who use drugs, like we have to understand, 546 00:33:03,089 --> 00:33:07,575 like, where might they be going afterwards or are used to going or, or how can 547 00:33:07,575 --> 00:33:11,585 we work with, whether it's community based organizations, syringe access 548 00:33:11,605 --> 00:33:17,444 programs, or just models of care in clinic, you know, in our institution, 549 00:33:17,444 --> 00:33:22,255 we have our, our HIV clinic, Ward 86, has a drop in model serving people 550 00:33:22,255 --> 00:33:24,045 experiencing homelessness called pop up. 551 00:33:24,494 --> 00:33:25,615 You can come in anytime. 552 00:33:25,664 --> 00:33:30,205 There are no appointments as, as there are similar sites sort of around the 553 00:33:30,205 --> 00:33:34,505 city, and I know around the country, if you are that person in the hospital 554 00:33:34,515 --> 00:33:36,885 thinking about, what are my resources? 555 00:33:36,895 --> 00:33:42,165 Like, who can I figure out that I can contact for this patient, to help them 556 00:33:42,185 --> 00:33:46,925 land more seamlessly, that would be one thing, and the other, I would say, 557 00:33:46,945 --> 00:33:50,634 is when thinking about that person leaving at midnight, as again, as 558 00:33:50,634 --> 00:33:53,825 Kinna said, like, we're going to try to figure out an oral antibiotic plan 559 00:33:53,825 --> 00:33:55,705 or some antibiotics better than none. 560 00:33:55,924 --> 00:34:00,725 The other thing that I don't think is too much to ask is, like, thinking 561 00:34:00,725 --> 00:34:04,185 about what harm reduction interventions you can offer, whether it's 562 00:34:04,185 --> 00:34:06,275 naloxone at bedside or at discharge. 563 00:34:06,475 --> 00:34:09,565 Our hospital recently started doing, like, providing safe 564 00:34:09,565 --> 00:34:11,765 consumption supplies at discharge. 565 00:34:12,055 --> 00:34:16,565 Leah Fraimow-Wong and team published this recently, JAMA Network Open, that's 566 00:34:16,565 --> 00:34:19,915 looking at, you know, how much patients and other stakeholders valued that. 567 00:34:20,465 --> 00:34:23,885 I'm really glad to hear you guys are giving out supplies 568 00:34:23,895 --> 00:34:25,065 to people at discharge. 569 00:34:25,065 --> 00:34:28,515 That was one of the things that really stood out to me in this. 570 00:34:28,615 --> 00:34:31,835 Like, why can't people just get what they need when they leave? 571 00:34:31,965 --> 00:34:35,074 It, it's medical supplies, so they should be able to get it. 572 00:34:35,665 --> 00:34:41,485 And the fact that this patient meets with a mobile health unit, that seems 573 00:34:41,485 --> 00:34:46,995 like such a missed opportunity to not have a syringe service program 574 00:34:47,095 --> 00:34:53,070 embedded there, or partnered there, anything low barrier is It's always 575 00:34:53,070 --> 00:34:54,960 going to be the best way to get people. 576 00:34:55,080 --> 00:34:56,570 People need community. 577 00:34:57,100 --> 00:35:00,600 Having low barrier services in the community instead of in 578 00:35:00,600 --> 00:35:04,329 the hospital setting is always going to be what folks need. 579 00:35:04,799 --> 00:35:06,309 Thanks Chasity. 580 00:35:06,600 --> 00:35:10,784 Well, I will round us out with our last scenario here. 581 00:35:10,895 --> 00:35:13,745 Um, this time we meet a 25 year old man. 582 00:35:14,215 --> 00:35:19,475 He is experiencing homelessness with chronic hepatitis C virus, opioid 583 00:35:19,475 --> 00:35:23,295 and stimulant disorders, and recent MSSA prosthetic valve endocarditis. 584 00:35:24,695 --> 00:35:29,025 He is receiving IV cefazolin through a PICC line at a local 585 00:35:29,025 --> 00:35:30,784 medical respite care center. 586 00:35:31,505 --> 00:35:34,845 Through the care center, which serves people experiencing housing 587 00:35:34,845 --> 00:35:38,935 insecurity, he can receive this continuous care, so IV antibiotics, 588 00:35:39,425 --> 00:35:41,245 following his hospital discharge. 589 00:35:41,754 --> 00:35:46,304 So, his additional treatment includes methadone for opioid use disorder 590 00:35:46,315 --> 00:35:50,845 and mirtazapine for stimulant use disorder, as well as counseling. 591 00:35:51,665 --> 00:35:55,725 Four weeks into treatment, he's still unable to secure housing and discovers 592 00:35:55,725 --> 00:35:57,935 that he has lost his job permanently. 593 00:35:58,515 --> 00:36:02,675 The respite care staff are alerted that a nurse found a syringe in his bed. 594 00:36:03,215 --> 00:36:06,025 There is concern that he had used his PICC to inject 595 00:36:06,025 --> 00:36:07,805 methamphetamine over the weekend. 596 00:36:08,420 --> 00:36:13,060 Otherwise, he is hemodynamically stable, doing well, and just prior 597 00:36:13,060 --> 00:36:16,430 to his scheduled ID follow up appointment that week, the respite 598 00:36:16,430 --> 00:36:20,340 care staff call and ask how they should proceed with his treatment. 599 00:36:20,930 --> 00:36:24,259 This is a tough scenario. 600 00:36:24,559 --> 00:36:29,210 Again, as in the other case, there are many things I think that this 601 00:36:29,210 --> 00:36:32,580 is going well here and that this is someone who is receiving shelter and 602 00:36:32,620 --> 00:36:37,500 is four weeks into his antibiotics on methadone and sort of interested in 603 00:36:37,500 --> 00:36:39,330 help for reducing his stimulant use. 604 00:36:39,870 --> 00:36:46,510 The approach that I take to learn more about ongoing substance use 605 00:36:46,890 --> 00:36:52,540 on addiction treatment and on infection treatment that may involve the PICC is 606 00:36:52,850 --> 00:36:56,940 first starting by setting the scene well, making sure that you have the time and 607 00:36:56,940 --> 00:37:02,549 space to have a conversation that's, you know, 15, 20 minutes longer, sit down, 608 00:37:02,670 --> 00:37:06,209 look your patient in the eye, hopefully you have developed a relationship, 609 00:37:06,399 --> 00:37:11,839 and then ask permission to have a conversation about ongoing substance use. 610 00:37:12,289 --> 00:37:15,349 And that may look like, hey, do you have a minute, a few minutes, like that. 611 00:37:15,660 --> 00:37:18,120 Can we talk a little bit about drug use. 612 00:37:18,460 --> 00:37:24,935 That scenario of Oh, I, you know, heard XYZ thing from someone in the 613 00:37:24,935 --> 00:37:28,675 care team that this person is using happens a lot or this comes up a lot 614 00:37:29,025 --> 00:37:32,334 and can often feel like telephone and knowing what truth is, is hard. 615 00:37:32,334 --> 00:37:36,644 And so I would start by sharing frankly what you've learned and then 616 00:37:36,890 --> 00:37:40,580 asking for their story or asking their understanding of sort of what's been 617 00:37:40,580 --> 00:37:42,230 going on or how things have been going. 618 00:37:42,490 --> 00:37:47,229 And then I really have loved Kina's article about shared decision making 619 00:37:47,439 --> 00:37:50,590 that references and I think brings up training that we've had around 620 00:37:50,590 --> 00:37:54,979 like ask, tell, ask and and really eliciting the patient perspective and 621 00:37:55,570 --> 00:37:59,290 continuously getting a sense of where they are when having this conversation. 622 00:37:59,560 --> 00:38:03,419 While this may feel disheartening, again, there are many successes that 623 00:38:03,419 --> 00:38:07,200 are happening here and that you can sort of approach this conversation 624 00:38:07,410 --> 00:38:13,599 and have one that is still warm, welcoming, and open one with, with 625 00:38:13,600 --> 00:38:17,800 your patient when trying to negotiate, okay, what, what's best moving forward. 626 00:38:18,325 --> 00:38:22,805 I think it's really important for people to hear and not expect that 627 00:38:22,815 --> 00:38:27,329 just because someone's in the hospital receiving treatment or on, you know, 628 00:38:27,720 --> 00:38:29,870 any sort of maintenance medication. 629 00:38:30,610 --> 00:38:32,300 That doesn't mean they're going to stop drug use. 630 00:38:32,880 --> 00:38:37,319 There's so many factors that go into that, and it's not black and white, 631 00:38:37,360 --> 00:38:42,119 so to expect that everything's just abstinence because someone's being treated 632 00:38:42,119 --> 00:38:45,220 for something is really concerning. 633 00:38:45,900 --> 00:38:49,990 I feel like this would be an opportunity to really say like, you know, This is 634 00:38:50,020 --> 00:38:56,140 why we need a safe supply like across the board for all medications and it would 635 00:38:56,150 --> 00:38:58,570 be a great time to advocate for that. 636 00:38:59,070 --> 00:39:04,370 I like what you said about having the conversations with the patient and asking. 637 00:39:05,300 --> 00:39:08,700 If you don't have a great relationship already built up, people aren't going 638 00:39:08,700 --> 00:39:12,710 to tell you anything because for so long, you know, this is drug use 639 00:39:12,710 --> 00:39:15,390 is just criminalized and shameful. 640 00:39:15,430 --> 00:39:20,665 So we have to lie and hide and hope that people are believing us when we 641 00:39:20,665 --> 00:39:23,675 know they probably aren't believing us, but we're not going to tell you 642 00:39:23,675 --> 00:39:25,545 the truth because it's shameful. 643 00:39:25,985 --> 00:39:30,034 Really being conscious about how you talk to people, that, that is great 644 00:39:30,034 --> 00:39:32,034 and I'm glad to see such a shift. 645 00:39:32,480 --> 00:39:35,990 Yeah, I totally agree with what both of you have said, and I will say this is 646 00:39:35,990 --> 00:39:40,170 actually based on, loosely based on a real case that we saw, and, you know, 647 00:39:40,170 --> 00:39:45,220 I think we did exactly that and, you know, we invited the patients for visits, 648 00:39:45,249 --> 00:39:50,920 asked permission to talk about things and, you know, describe any triggers you 649 00:39:50,920 --> 00:39:54,610 may have had, and, um, In reality, in terms of, like, the clinical management, 650 00:39:54,610 --> 00:39:57,570 if helpful, you know, we did check, you know, 2 sets of blood cultures, 651 00:39:57,570 --> 00:40:01,739 CBC with diff, CMP, CRP CRPn, and, um, what we did is really just, you know, 652 00:40:01,740 --> 00:40:07,050 document the structured conversation, trying to, you know, again, talk about 653 00:40:07,060 --> 00:40:08,700 the different antibiotic options. 654 00:40:08,729 --> 00:40:11,700 The patients still want the PICC, do they want to do long acting 655 00:40:12,140 --> 00:40:15,350 instead, or oral antibiotics, and, you know, just making sure that he 656 00:40:15,350 --> 00:40:17,580 had, access to safer use equipments. 657 00:40:18,200 --> 00:40:21,300 And also the other thing we did was reaching out to make sure that the 658 00:40:21,320 --> 00:40:23,670 respite care center had naloxone on site. 659 00:40:23,670 --> 00:40:27,270 Everyone was trained in overdose reversal, which they were, which is great. 660 00:40:27,310 --> 00:40:31,000 So, you know, for this particular case, we, you know, wouldn't, wouldn't recommend 661 00:40:31,245 --> 00:40:34,905 for him to go to the hospital or pull the PICC line, because, you know, it ended 662 00:40:34,905 --> 00:40:39,005 up being his preference that to keep the PICC in and, you know, he under, we kind 663 00:40:39,005 --> 00:40:40,924 of went through safer use practices. 664 00:40:41,375 --> 00:40:43,184 We know that he has hepatitis C. 665 00:40:43,185 --> 00:40:47,815 So, I think it's just probably important to flag that substance use is also not 666 00:40:47,815 --> 00:40:49,675 a contraindication to hep C treatment. 667 00:40:50,075 --> 00:40:53,585 So we do want to end the hep C epidemic. 668 00:40:53,585 --> 00:40:58,455 I think it's really important that we treat people who use drugs and it's 669 00:40:58,455 --> 00:41:03,025 probably worth noting too, that there's a bunch of places, Madeline McCurry and 670 00:41:03,025 --> 00:41:06,505 colleagues wrote a nice paper on this, but there's a lot of places that have created 671 00:41:06,505 --> 00:41:10,565 processes for, you know, discharging people who use drugs with prescriptions 672 00:41:10,575 --> 00:41:14,105 for hep C treatment, or at least starting the process for hep C treatment 673 00:41:14,105 --> 00:41:15,585 in the hospital or just afterwards. 674 00:41:15,805 --> 00:41:20,915 I'm just encouraging ongoing screening as needed afterwards in case of reinfection, 675 00:41:20,925 --> 00:41:24,545 which honestly the rates of reinfection thus far is, you know, fairly low, 676 00:41:24,585 --> 00:41:27,005 so just a plug for hep C treatment. 677 00:41:27,415 --> 00:41:28,605 I'm so glad you brought that up. 678 00:41:28,654 --> 00:41:28,955 It's true. 679 00:41:28,955 --> 00:41:31,024 I think there was just some, there's an article in the Lancet, I forget 680 00:41:31,025 --> 00:41:34,064 which one, that is essentially like, we're not doing, we're not doing 681 00:41:34,065 --> 00:41:36,365 so great with hep C elimination. 682 00:41:36,925 --> 00:41:37,315 I agree. 683 00:41:37,315 --> 00:41:42,305 I love the work that people have been doing, innovating to, to, hep C treatment 684 00:41:42,305 --> 00:41:43,875 earlier, but this case is a good example. 685 00:41:43,885 --> 00:41:47,285 Like he's four weeks into treatment, could have been four weeks into hep C treatment. 686 00:41:47,665 --> 00:41:48,065 Exactly. 687 00:41:49,304 --> 00:41:54,054 Well, I am so so grateful that you guys joined Febrile and, you know, 688 00:41:54,054 --> 00:41:57,035 helped us think about how to take care of the example scenarios here. 689 00:41:57,035 --> 00:42:03,935 I just want to leave the ending here for asking if you have any additional 690 00:42:04,295 --> 00:42:08,535 either take home points or highlights that you want to make sure we talk 691 00:42:08,544 --> 00:42:10,225 about before we finish up the episode. 692 00:42:10,555 --> 00:42:17,295 I just really want to say that I appreciate that harm reduction is being 693 00:42:17,425 --> 00:42:19,855 recognized on a much larger scale. 694 00:42:20,820 --> 00:42:25,550 I also need to acknowledge that it's not being recognized in 695 00:42:25,550 --> 00:42:29,020 appropriate ways across the board. 696 00:42:29,340 --> 00:42:33,770 It's really important to continue having conversations and letting 697 00:42:33,770 --> 00:42:36,799 people know, like, people who use drugs, they're just people. 698 00:42:36,809 --> 00:42:38,670 Like, the who use drugs part doesn't matter. 699 00:42:38,689 --> 00:42:39,780 We're all just people. 700 00:42:40,320 --> 00:42:42,219 We are no different than anybody else. 701 00:42:42,589 --> 00:42:43,479 Yeah, that's it. 702 00:42:43,970 --> 00:42:50,830 A take home point from my angle is that these cases, which we see all 703 00:42:50,840 --> 00:42:57,109 the time, right, are so common, all included areas in which there's a lot 704 00:42:57,240 --> 00:43:04,080 of uncertainty in the medical literature around, you know, How best to choose 705 00:43:04,090 --> 00:43:08,650 the right set of oral antibiotics, or oral versus injectable, et cetera. 706 00:43:08,930 --> 00:43:13,060 How best to couple infection treatment with substance use disorder 707 00:43:13,060 --> 00:43:16,040 treatment, or infection treatment with harm reduction interventions. 708 00:43:16,270 --> 00:43:21,240 So we need a ton of more data, and we also need a ton of work that 709 00:43:21,240 --> 00:43:24,060 centers the patient voice in all of this, like what do patients want? 710 00:43:24,080 --> 00:43:25,180 What works for them? 711 00:43:25,490 --> 00:43:29,650 Again, sort of traversing the inpatient outpatient spectrum and, and providing 712 00:43:29,650 --> 00:43:32,890 really good models of care that are, that are truly patient centered. 713 00:43:33,080 --> 00:43:38,540 And similarly to support that, whether it's grant mechanisms or IDSA and CROI, 714 00:43:38,569 --> 00:43:42,500 shout out to those to, to, you know, add, continue to think about focusing 715 00:43:42,500 --> 00:43:44,590 on this area will be really helpful. 716 00:43:44,590 --> 00:43:46,460 And we've talked a lot about barriers. 717 00:43:46,590 --> 00:43:52,810 I think on a hopeful note, I'm really grateful that to work with people who 718 00:43:52,810 --> 00:43:57,110 use drugs or folks that have not been in the lines of antibiotic treatment 719 00:43:57,460 --> 00:44:01,150 or, or like what we normally do, because I think it is a nice opportunity 720 00:44:01,150 --> 00:44:04,710 to push us outside of like, what are our evidence based treatments? 721 00:44:04,710 --> 00:44:05,840 Like, what are they based on? 722 00:44:05,859 --> 00:44:09,630 And how can we think outside the box and have better fit into people's lives? 723 00:44:09,690 --> 00:44:09,930 Yeah. 724 00:44:09,930 --> 00:44:15,820 At the end of the day, I think when caring for people, drawing on 725 00:44:15,860 --> 00:44:20,150 principles of shared decision making and harm reduction can just really 726 00:44:20,150 --> 00:44:23,220 help to optimize patient autonomy. 727 00:44:23,240 --> 00:44:26,280 Like you said, Ayesha, just making sure that we include patient voices 728 00:44:26,720 --> 00:44:30,510 and really optimize health and safety, which is at the end of the day what 729 00:44:30,510 --> 00:44:32,740 we want for all of our patients. 730 00:44:33,680 --> 00:44:35,510 Last, I just want to add one piece. 731 00:44:35,540 --> 00:44:42,045 I think in talking about harm reduction and especially in medical settings that 732 00:44:42,215 --> 00:44:47,344 it's a great opportunity for everybody to really be advocating across the board 733 00:44:47,344 --> 00:44:52,754 for access to a safe supply, overdose prevention centers, need based syringe 734 00:44:52,754 --> 00:44:58,530 service programs, and change all the policies like We could be leading the 735 00:44:58,530 --> 00:45:02,070 way instead of having to be reactionary. 736 00:45:02,180 --> 00:45:06,670 I'd love to also just put in a plug for IDSA's member advocacy program, or MAP. 737 00:45:06,670 --> 00:45:10,560 You can go on the website and sign up and get involved with a 738 00:45:10,560 --> 00:45:13,150 lot of these policy changes, too. 739 00:45:14,240 --> 00:45:18,340 Thanks again to our guest stars, Kinna, Ayesha, Chasity for joining Febrile today. 740 00:45:19,030 --> 00:45:22,810 You can find their article, Frame Shift, Focusing on harm reduction and 741 00:45:22,810 --> 00:45:26,300 shared decision making for people who use drugs, hospitalized with infections 742 00:45:26,690 --> 00:45:29,280 linked in the episode information and on the Consult Notes. 743 00:45:29,950 --> 00:45:32,370 Don't forget to check out the website, febrilepodcast. 744 00:45:32,400 --> 00:45:36,130 com, where you can find our Consult Notes, the library of ID infographics, 745 00:45:36,150 --> 00:45:37,440 and a link to our merch store. 746 00:45:38,129 --> 00:45:40,790 Febrile is produced with support from the Infectious Diseases 747 00:45:40,800 --> 00:45:42,770 Society of America, IDSA. 748 00:45:43,520 --> 00:45:45,730 Editing and mixing is provided by Bentley Brown. 749 00:45:45,969 --> 00:45:48,809 Please reach out if you have any suggestions for future shows or want 750 00:45:48,810 --> 00:45:49,960 to be more involved with Febrile. 751 00:45:50,590 --> 00:45:52,940 Thanks for listening, stay safe, and I'll see you next time.