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Trusting Injection Drug Customers With IV Antibiotics At House: It Can Work – Kaiser Well being Information

This story is part of a partnership that includes WBUR, NPR and Kaiser Health News.

This story can be republished free of charge (details).

Two mornings a week, Arthur Jackson clears space on half of his cream-colored sofa. He puts out a few rolls of tape and some gauze and waits for a knock on his front door.

"This is Brenda's desk," Jackson said with a giggle.

Brenda Mastricola is his nurse. After arriving at Jackson in Boston, she sits on the couch with him and starts measuring his blood pressure. Then she changes the bandages on Jackson's right foot. His big toe was amputated at Brigham and Women's Hospital in November. A bacterial infection, osteomyelitis, had destroyed the bone.

Jackson is still taking penicillin intravenously to stop the infection. He came home from the hospital with a small medication pump that delivers a constant dose of penicillin through a PICC line. PICC stands for a "peripherally inserted" or "percutaneously staying" central catheter and resembles a flexible IV tube that is inserted into Jackson's chest.

"It all looks good," said Mastricola after making sure the line was clean and in place. "You do not need me."

If patients need weeks or months of intravenous antibiotic treatment but do not otherwise need to be hospitalized, the standard protocol is to discharge them with a PICC lead and allow them to stop medication at home. It saves money and is much more convenient for patients.

However, this regulation is almost never offered to patients with addiction history. The fear is that such patients may be tempted to use the PICC line as a quick and easy way to inject drugs such as heroin, cocaine, or methamphetamine.

Jackson, 69, was addicted to heroin for 40 years. Although he's been sober for years, most U.S. hospitals force patients like Jackson to stay in the hospital sometimes eight weeks or more. But Brigham and Women in Boston and a few others in the United States question this protocol and allow some patients with a history of addiction to go home.

Proponents of the change argue that this increases the chances that these patients will stay on their antibiotics and fight the infection.

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A way to safe treatment at home

A small team of Brigham doctors and nurses began planning this unusual option shortly after the opening of Bridge Clinic, a walk-in health center in Boston for patients seeking treatment for a substance use disorder. Dr. Christin Price, one of the clinic's directors, said that practically every patient who injects medication develops an infection. It is difficult to avoid injecting bacteria into the bloodstream when drugs are used in an alley or in a public bathroom. The national opioid epidemic has in many cases led to a parallel increase in diseases related to the use of injection drugs such as HIV, hepatitis C and bacterial infections of the heart and bones. A study by hospitals in North Carolina showed a twelve-fold increase in cases of bacterial endocarditis, a heart infection, from 2010 to 2015.

"Every time someone uses injectables, they put themselves at risk of a very complicated infection," Price said.

The treatment options for endocarditis patients with a history of drug use are limited. Some qualified care facilities, home care agencies and antibiotic infusion companies refuse to work with these patients once they are discharged from a hospital. And, Price said, some of their patients are unwilling to stay in hospital for weeks just to stop a round of IV antibiotics.

"You are going crazy somehow," she said. "You can imagine that it is almost like being held captive for six weeks, especially if you feel good now that the infection is improving. A big problem is that some of them cannot survive – and therefore leave before the six weeks are up. ”

Patients who have not completed their antibiotic course may experience recurrent infection and a repeated trip to the hospital.

Bridge Clinic doctors and nurses wondered if there was a way to safely send patients with a history of drug use home. They set three requirements: First, patients would need to take an addictive drug like buprenorphine or be ready to start one. Second, patients would have to check into the Bridge Clinic weekly. Third, patients should have stable accommodation and live with a sober friend or loved one. Price and colleagues began months of discussions with specialists in heart, bone and joint diseases to get surgeons and nurses to buy them so that their patients could participate.

"A lot of people looked kind of horrified," Price said. "It was just their policy that people with a history of injection drug use would not go home."

As Dr. Daniel Solomon, who is also at Brigham and Women, encountered these looks and reminded his colleagues that "the alternatives are not that good either".

Keeping patients in a hospital room for weeks is difficult for both patients and medical providers, he said. And if patients want to take drugs, they will find a way to do it in a hospital bed.

In the spring of 2018, Price, Solomon and others admitted some of the first qualified patients, then some more – intentionally those who wanted to be treated and had a sober, stable home.

Brenda Mastricola is reviewing the PICC line, through which Arthur Jackson, a former drug user, receives penicillin for the treatment of a bone infection. (Jesse Costa / WBUR)

"I'm not going back"

Arthur Jackson met the requirement that PICC line candidates be required to take addiction medication at home. He had been taking methadone for 10 years, consuming heroin again, and then switching to Suboxone, a combination drug with buprenorphine and naloxone that he had been taking for two years. In fact, Jackson said he was offended when one of the doctors presented him with the option for home treatment, but said she was concerned that the PICC line could lead him to inject heroin.

"Stop right there," Jackson recalled when he told the nurse. "When it comes to my recovery, I'm serious because I've done so much to lick this – this thing."

Although Jackson thought of the possibility.

"The first thing I thought was," Oh, I could easily inject heroin here, "Jackson said." But I rejected that thought because I don't go back "- back to the winter on the street and from a heroin – Live to the next.

Other Bridge patients ridicule concerns about PICC lines.

"Everyone does such a big deal with this PICC line," said Stephen Connolly, 36, who went home with the open port last year while being treated for endocarditis. “If I want to go high, I know how to do it. I'm not going to mess around with a PICC. "

Connolly said when he first came to Brigham and Women's Hospital, he focused on his heart and ignored his other illness: addiction. He said he was surprised when every doctor he saw, including his cardiologist, wanted to talk about addiction.

"I'm like" Listen, dude. My heart is falling apart here, so let's keep up with the drug talk, "Connolly recalled. He assured the cardiologist that he was in control of his addiction, although he wasn't so sure." Of course I didn't, but mine Mind tells me that. It's just crazy. "

Connolly said he now realized that the conversation about drug use was relevant and related to his heart infection.

Connolly ended his antibiotic treatment while staying with family members in Abington, Massachusetts. The doctors in Brigham say that the housing needs exclude otherwise eligible patients. Recent research shows that homeless patients with HIV or Hep C are taking their antiviral drugs. There are no comparable robust studies on the treatment of homeless patients with bacterial infections.

Nevertheless, some other hospitals are testing ways to continue outpatient treatment for patients who do not have a stable home. In Portland, Oregon, a medical center attempted to provide IV antibiotics as part of addiction treatment programs. A Kentucky hospital combines addiction treatment, counseling, and outpatient IV antibiotics. In Vancouver, British Columbia, the Canadian National Health Program pays for small, 24-hour nursing homes that patients can stay in while completing antibiotic treatment.

"People who use drugs deserve the same standard of care," said Dr. Christy Sutherland, medical director of the Portland Hotel Society in Vancouver. "We cannot change what we offer as clinicians – to treat people below average, with the excuse that they are IV drug users."

Promising early signs

Arthur Jackson lives alone in his studio apartment (he doesn't live with a sober friend or loved one), but he convinced the doctors that he was better off there than in the hospital to visit his 93-year-old could. The old mother feeds his tank of tropical fish and his cat daily and takes part in regular meetings with anonymous narcotics.

"I think the best way to put it is I have a life and I have to get back to it," he said.

Jackson is one of 40 prehistory drug users the Brigham team released from hospital to complete intravenous antibiotic treatment at home. The team pays special attention to 21 patients in this group who, unlike Jackson, are active drug users. So far, these men and women have completed their antibiotic treatment on a PICC line without complications. One had to be re-admitted because of difficulty in administering the antibiotics. Price said three patients had dropped back to drug use, but no one had used the PICC line to inject illicit drugs.

"I think we have shown through this pilot that it is safe and doable for certain patients," Price said.

The doctors in Brigham have not yet published these first results in a medical journal, although they intend to do so. Price said, however, that the pilot program will help reduce healthcare costs.

As a group, the 21 high-risk patients who needed IV antibiotics spent 571 days at home and not in a hospital or rehab facility. Without the cost of home nursing visits by a home nurse, the savings amount to more than $ 850,000, based on estimates of $ 1,500 per hospital day.

This story is part of a partnership that includes WBUR, NPR and Kaiser Health News.

This story is part of a partnership that includes WBUR, NPR and Kaiser Health News.

This story can be republished free of charge (details).

Martha Bebinger, WBUR:

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