A doctor friend of mine sent me an article from the New England Journal of Medicine from November 13. 2014. I subscribe to the NEJM, but somehow overlooked this article, so I’m happy he brought it to my attention. My friend reads my blog and knows I have lamented how I was taught in my Internal Medicine residency to treat endocarditis (potentially life-threatening infection of a heart valve), but not the underlying cause, which was addiction (read in my blog post of December 7, 2014).
The journal article he sent me is a case study of a young woman with endocarditis from intravenous drug use. The case study begins in the usual way, describing her history and physical findings. Nothing was uncommon here: the patient told them she was a drug user, and she had track marks, fever, and a heart murmur. The history and physical findings screamed, “Endocarditis! “ A chest x-ray and then chest CT scan showed multiple septic emboli, commonly seen with endocarditis, sealing the diagnosis.
But this case wasn’t only about the diagnosis and standard treatment with antibiotics. To my delight, the first sentence describing the case management was “Methadone was administered orally.”
But as it turned out, the patient was only put on a methadone taper while hospitalized. She was started on a protracted course of antibiotics and sent to an extended-care facility, where she quickly relapsed. This relapse illustrated the second point of the article: medication-assisted therapy must be continued to be effective.
As the case discussion points out, “As with other medications for chronic diseases, the benefits, at least in the short term, last only while the patient is taking the medication.” In other words, her relapse was predictable, and not due to failure on the part of the patient. The relapse happened because of failure to continue the medication by the doctor.
A little later in the case study I read these wonderful sentences: “Although making a diagnosis of endocarditis is a crucial first step (emphasis mine), understanding the root cause of the endocarditis is a key feature in the diagnosis and management of this patient’s illness. Endocarditis is only a symptom of her primary illness, which is an opioid-use disorder.”
I loved this case presentation for two reasons: it emphasized treating the entire patient, including the underlying disease of addiction, and it pointed out that short-term medication with methadone or buprenorphine doesn’t work, just like temporary treatments for other chronic diseases don’t cure anything.
This patient developed endocarditis again after her relapse, and needed a second hospitalization. This time, she left the hospital on buprenorphine maintenance. She relapsed again after two months, had a third episode of endocarditis, this time due to a fungus, and required a third hospitalization.
After that treatment was over, she was maintained on buprenorphine. At the end of the article, the authors reported that the patient had over a year of abstinence from drug addiction, was taking buprenorphine, and going to AA and NA regularly.
In the discussion of appropriate treatment of both the endocarditis and the opioid addiction, I read this delightful sentence::The opioid agonists methadone and buprenorphine are among the most effective treatments for opioid-use disorder.”
Can I get an “Amen!”?
The same paragraph goes on to describe the benefits seen with MAT, which include decreased opioid use and drug-related hospitalizations, and improved health, quality of life, and social functioning. This article also clearly states MAT will reduce the risk of opioid overdose and death. Many references are cited at the end of the article for non-believers in MAT.
This article also included recommendations about educating patients about overdose risk, and providing them with naloxone.
At the end of the article, the patient who was the subject of this case study discussed her perspectives regarding her treatment. She related how each time in the past, she was treated for whatever medical problem she had, and then sent on her way, with little effort to treat her addiction. She says she’s grateful for the second episode of endocarditis, because she met the doctor who treated the addiction and gave her hope that she had a treatable disease. Prior to that, she doubted she could stop her active addiction, because she saw herself as a bad person, not as a sick person.
This article ends with this patient’s words: “To be honest, I never thought I would be standing here, clean for over a year. I thought that I was going to die.” That effectually describes the hopelessness of patients in active addiction.
I hope such endorsement of medication-assisted treatment of opioid addiction by the prestigious New England Journal of Medicine will help convince more doctors of the legitimacy of MAT.
During my training in the 1980’s, I didn’t learn how to treat the underlying cause of the endocarditis. I am delighted and encouraged to find the New England Journal of Medicine has published an article that does just that. This article clearly and overtly states the importance of treating the real problem, not just symptoms of the problem. Today’s doctors have a valuable opportunity to change the lives of many of their future patients.