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Open Collection of Student Writing (OCSW)

PICC A Time for Change: Review and Recommendation for Infectious Disease Related to Substance Use Disorder

A 12 to 18 millimeter gauge entered into an arm, chest or neck threaded 50 to 60 centimeters through the vein into the hearts major veins. The purpose is daily transportation of antibiotics for a potentially deadly infection. A peripherally inserted central catheter, known as a PICC Line lays the foundation for saving a life. People who inject drugs (PWID) often have unique barriers to health care. In this paper, PICC use for PWID and its ethical implications will be explored by addressing if it is appropriate to limit medical treatment options to PWID due to their lifestyle choices.

A PICC line gives your doctor access to the large central veins near the heart. It is used to give antibiotics and antifungal medicines for serious infections such as infective endocarditis (IE), joint infections, bacteremia, abscesses, MRSA staph infection and skin infections. All of which can be caused by complications due to intravenous drug use requiring long-term hospitalization depending on the infection site and severity. A PICC line requires careful care and monitoring for complications, including infection and blood clots. (Mayo Clinic, 2019)

In London, Ontario, a study was conducted with 212 participants who inject drugs that were diagnosed with endocarditis. This study is important because it presents the problem how biases along with lack of resources can be detrimental when handling emergency situations amidst individuals with a substance dependency. Among 212 PWID, 68 patients were there with a second episode of endocarditis, 22 with a third recurrence, and 5 with a fourth recurrence.  Only 20% of the participants were given a referral to treatment for their substance dependency disorder. (Rodger et al., 2019)

Equity in Care for PWID

Two Canadian studies show positive results for interventions that offer PICC for PWID. Vancouver, Canada came up with a “Community Transitional Care Team” (CTCT) for people who use drugs that needed IV antibiotics. The goals being to increase retention and antibiotic adherence leading to treatment completion, to reduce leaving Against Medical Advice (AMA), to decrease the average hospital length of stay, to facilitate the transition from acute inpatient care to community and to reduce emergency room use. Of the 165 patients admitted to CTCT, 84% were using at least one illicit drug at admission, 39% were injection the drugs. (Jafari et al., 2015)

One hundred percent of the patients reported that the CTCT program is welcoming, sensitive to their social and medical needs, and characterized the staff as skilled and understanding. Feedback from the patients included “they accept you for who you are. You don’t have to be anybody else “and “the CTCT literally saved my life”. The findings indicated the risk of leaving AMA was significantly lower among clients who were staying at CTCT, with only 2 patients going AMA. Another important accomplishment of CTCT was discharging clients to a stable housing. A total of 36 % were homeless in admission and all of them were discharged to a stable housing at the completion of their antibiotic therapy. (Jafari et al., 2015)

Another study in Canada researched the idea of Patient-Centered Care (PCC) involving 30 people who use drugs (PWUD). They found that changing the meso-environmental context of hospital care by implementing harm reduction approaches has the potential to mediate micro-social/physical environmental conditions that foster PCC for drug misuse populations and improved hospital outcomes. While PWUD have diverse health needs and experiences, there is considerable evidence that their pain and withdrawal symptoms are routinely ignored in hospitals as the result of anti-drug stigma, racism, and abstinence-based hospital policies. Unmanaged pain and withdrawal symptoms foster severe suffering, and leads to discharges from hospital against medical advice. The findings suggest that enabling PWUD to manage pain and withdrawal in consultation with their attending physician (i.e., opioid assisted treatment) or by injecting on their own (i.e., supervised drug consumption services) significantly improved hospital care retention and minimize drug-related risks. (McNeil et al., 2016)

Heart Valve Replacement Surgery in PWID

Heart valves control how blood flows into and out of the heart. Valve operations are critical when a defect is detected inhibiting the bloods flow. (Yale Medicine, 2020) Replacing a heart valve in PWID in controversial. Particularly, with recurrent cases due to a perception of a very high risk of further reinfections. University Health Network and University of Toronto says these situations raise two questions. First, is a history of certain behaviors an ethically defensible reason to restrict a patient’s (repeated) access to a potentially lifesaving health care resource? Second, should a PICC be inserted for home intravenous (IV) use in a person who uses drug(s)? (Buchman et al., 2018)

Clinical management should involve not only treatment of the infected valve, but also an effort to address the micro level modifiable risk factors associated with relapse to drug misuse and reinfection. Experiences suggests there is often a double standard applied to PWUD. Questions about the medical futility of repeated surgical interventions are less likely to arise in treatment considerations surrounding other so-called lifestyle-associated conditions, such as those secondary to tobacco use, obesity, and high-risk activities. (Buchman et al., 2018)

Utah Dares to Provide a Different Approach

In 2014 Medical Director of Riverton Hospital at Intermountain Health Care (IHC) started to find an increase in Utah’s number of patients arriving in the hospital with injection-related infections from heroin and methamphetamine use. ”I think what I recognized is that we were missing key parts to care and that what we were failing to recognize when patients were coming in is that they were withdrawing from their drug, which created behavioral issues leading to either patients leaving against medical advice, or creating such a disruption that we had to discharge them.” Dean Mayer, interview by Healthy Mind Matters, KSL, February, 13, 2020.

Odyssey House of Utah Provides Substance Residential Support for PWID requiring a PICC line

The IHC PICC Program collaborated with Odyssey House of Utah to transition patients directly from the hospital into residential treatment services. The patient administers their own IV antibiotics daily while IHC home health care nurses visits the patient weekly to monitor the infection. This allows the patient to receive antibiotics for their physical infection while Odyssey House provides Medication-assisted treatment (“MAT”) to help manage withdrawal symptoms if the patient desires the help. The two critical pieces combined with daily therapy addressing their substance dependency behaviors in a Therapeutic Community setting offering a full continuum of care. (Proven Treatment, 2020)

Odyssey House of Utah CEO explains, “This innovative, collaborate approach is literally saving lives,” “Working together, we are reducing the tragic and unnecessary deaths we’ve seen from the opioid epidemic.” Adam Cohen, interview by Healthy Mind Matters, KSL, February, 13, 2020.

Infections severe enough to require a PICC line, hospitalization is required. This can present a pivotal opportunity to introduce supportive programs in an attempt to engage individuals to a substance dependency treatment program. Changes to the social-structural contexts of hospital settings can transform them from ‘risk environments’ into ‘safer environments’ for drug misusing populations. If a person who participates in extreme snowboarding and has suffered bone fractures requiring multiple surgeries would not be disqualified from future surgeries if that person continued to snowboard. This example challenges our intuitions about “risk” behaviors and who is owed what and why. (Buchman et al., 2018). Awareness of disparities in hospital outcomes among PWUD points to the need for action to better align care with their needs consisting of building trust, having compassion without judgement and acceptance to value human life regardless of what challenges they are facing. Simple changes by ways of words and actions indicating we see you. We are not here to judge you. You have options for you. You are worthy

One Heroes Journey

Jamie Shaw, 47, was one of the first PWID PICC line patients who utilized the IHC program to get into treatment with Odyssey House. Shaw said he was “running and gunning” for 20 years, misusing alcohol, cocaine, and methamphetamines. While under the influence of meth in May of last year he attempted suicide and was rushed to Intermountain Medical Center in Murray where doctors saved his life. If he wouldn’t have been able to get drug treatment while he was on the PICC line he said, “I would be dead now. It saved my life.” See Shaw’s full story at https://www.youtube.com/watch?v=ft1dCPo32Uk.

Works Cited

Buchman, Daniel Z., and Marie-Josee Lynch. “An Ethical Bone to PICC: Considering a Harm Reduction Approach for a Second Valve Replacement for a Person Who Uses Drugs.” American Journal of Bioethics, vol. 18, no. 1, Jan. 2018, pp. 79–81.

“Heart Valve Replacement.” Yale Medicine, Yale Medicine, 22 Oct. 2020.

Jafari Siavash, Ronald Joe, Danielle Elliot, Ashnoor Nagil, Sargent Hayden and Marsh David.  “A Community Care Model of Intravenous Antibiotic Therapy for Injection Drug Users with Deep Tissue Infection for ‘Reduce Leaving Against Medical Advice.’” International Journal of Mental Health & Addiction, vol. 13, no. 1, Feb. 2015, pp. 49–58.

“MAT Medications, Counseling, and Related Conditions.” SAMHSA, 19 Aug. 2020

Buprenorphine, methadone, and naltrexone are used to treat opioid use disorders to short-acting Opioids such as heroin, morphine, and codeine, as well as semi-synthetic opioids like oxycodone and hydrocodone.

Matters, Healthy Mind. “Intermountain Healthcare Working with Communities to Address Opioid Use Disorders.” KSL.com, 13, Feb. 2020

McNeil, Ryan, Kerr Thomas, Pauly Bernie, Wood Evan and Small Will. “Advancing Patient Centered Care for Structurally Vulnerable Drug-Using Populations: a Qualitative Study of the Perspectives of People Who Use Drugs Regarding the Potential Integration of Harm Reduction Interventions into Hospitals.” Addiction (Abingdon, England), U.S. National Library of Medicine, Apr. 2016.

“Peripherally Inserted Central Catheter (PICC) Line.” Mayo Clinic, Mayo Foundation for Medical Education and Research, 29 Aug. 2019, www.mayoclinic.org/tests- procedures/picc-line/about/pac-20468748.

Proven Treatment, 2020, www.odysseyhouse.org/about/treatment-methods.

Rodger Laura, Meera Shah, Esfandiar Shojaei, Koivi Sahron and Silverman Michael. “Recurrent Endocarditis in Persons Who Inject Drugs.” Open Forum Infectious Diseases, vol. 6, no. 10, Oct. 2019, p. N.PAG.

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