Endocarditis Joins HIV and Hepatitis Among Infections Related to Opioid Epidemic: Public Health Watch

The pain of the ongoing opioid epidemic in the United States apparently knows no bounds.

With US Department of Health and Human Services data suggesting that more than 11 million Americans misused prescription opioid analgesics in 2016—the last year for which data are available—there are, not surprisingly public health implications associated with the crisis that go beyond issues of addiction and deaths related to overdose. And also, not surprisingly, given that many of those misusing opioids take them via injection, and share needles, at least some of these challenges have an infectious disease component.

In a report by Fox 25 in Boston, health care officials in Massachusetts, which has seen high rates of opioid misuse in recent years, acknowledged that they have seen a rise in endocarditis, particularly among teens and young adults. Given that endocarditis is more commonly diagnosed in older adults, officials in the Bay State have attributed this disturbing trend to injection drug use, suggesting that young people may be exposed to the bacteria that causes the disease because they are not disinfecting the area around the injection site prior to inserting the needle.

“On any given day we have half a dozen young people who are suffering from [endocarditis],” Sarah E. Wakeman, MD, Medical Director, Substance Use Disorder Initiative, Massachusetts General Hospital, Boston told the television station.

In addition to the anecdotal evidence, the Fox 25 report cited a study performed at Tufts University, in nearby Medford, and published in the July 2016 issue of Open Forum Infectious Diseases, which found that hospitalizations due to injectable drug-related endocarditis in the state more than doubled between 2000 and 2013. Over this same period, the percentage of hospitalized patients between the ages of 15 and 34 increased from 27.1% to 42.0%.

And Massachusetts is hardly alone in this regard. A study published in the June 9, 2017 issue of the US Centers for Disease Control and Prevention’s (CDC) Morbidity and Mortality Weekly Report (MMWR) found that hospitalizations attributed to injectable drug-related endocarditis increased 12-fold from 0.2 to 2.7 per 100,000 persons. The sharpest increases were found in the 18 to 25 age group.

Of course, endocarditis isn’t the only infectious risk associated with injection opioid use. As noted in a commentary published in the March 29 issue of The New England Journal of Medicine (NEJM), the number of new cases of hepatitis C in the United States has increased from around 10,000 per year in 2005 to more than 40,000 per year in 2016. The authors write that “[t]his increase has been driven largely by transmission among white adults in their 20s and 30s, particularly those living in nonurban areas. Many of these people initially became addicted to prescribed oral opioids and later switched to intravenous opioid use, which carries a high risk of HCV infection.”

They add that transmission of other blood-borne infections such as HIV and hepatitis B is also on the rise among drug users. Contagion^® has reported on some of the disturbing trends with regard to hepatitis C and HIV in the past.

To address the problem posed by drug misuse-related HCV infection, the authors of the NEJM commentary recommend implementation of programs offering increased access to free and/or low-cost disease testing as well as addiction treatment services. They also suggest “syringe programs for injection-drug users, in clinical settings where HCV prevalence is often high”—namely: emergency departments, urgent care clinics, and prison clinics—and “in community health centers that provide preventive services to young adults, including pregnant women.” Of course, such “safe injection sites” have traditionally been viewed as a controversial solution to a complex problem, at least in the United States, where Philadelphia is working toward becoming the first city in the country to put the idea into practice, according to NPR.

However, controversy aside, it is clear that out-of-the-box solutions are needed to stem the disturbing tide of infectious disease outbreaks related to opioid drug use. The data has spoken, and the story it’s telling won’t have a happy ending unless some action is taken.

Brian P. Dunleavy is a medical writer and editor based in New York. His work has appeared in numerous health care-related publications. He is the former editor of Infectious Disease Special Edition.