Mark Briesacher, MD: Hi, this is Mark Briesacher. I'm the Chief Physician Executive at Intermountain Healthcare, and I'm here today with three colleagues of mine, Mike Coudreaut who is a psychiatrist and Consultation Liaison at Intermountain Medical Center, Eddie Stenehjem who is the Medical Director of Antibiotic Stewardship. Eddie’s an infectious disease doctor, and Dean Mayer, who is the Medical Director out at Riverton Hospital and a hospitalist. We're here to talk about a pretty tough issue in our community, and that is the issue of our opioid epidemic, drug addiction, intravenous drug use, and then a problem that a lot of people don't talk about in this conversation, which is a tough, tough complication for intravenous drug users, and that is infection of the heart valves, or endocarditis.

Eddie Stenehjem, MD: The story that I recall vividly is one that we all were involved with. This was a number of years ago. I remember this patient vividly. She was a young woman, mother of two. I met her on the consultative service at Intermountain Medical Center when I was seeing infectious disease patients. When I walked into her room, she was shaking, cold, with a high fever. Her family was there. We found out this was her third episode of infection of her heart valves. All three of these episodes were due to her habit of injecting illicit drugs. In this case, it was heroin. These infections, when they're this severe and this far along, have to be managed surgically. We just cannot treat them with antibiotics alone. We were in a really tough position, the team was, to have to decide whether or not we offer this patient a second surgery. She'd already had a previous surgery to remove her valve. We didn't have a good system in place to offer her the drug treatment counseling that she really needed. That was the first time that this team that really assesses these patients came together to advocate on the patient's behalf, and really engage the community within Intermountain Healthcare and find the best treatment for her.

Mark Briesacher, MD: Then what happened?

Eddie Stenehjem, MD: We went through a series of meetings. We got her stabilized. We engaged her and the family. We had psychiatry involved. We had the hospital medicine service involved. We had infectious disease service involved. Importantly, we had cardiothoracic surgery involved. We talked to the patient frankly. She understood that she was in a tough position and she was going to die without surgery. Engaging everybody in a multidisciplinary team and a collaborative approach, we were able to find care for her with her family's assistance to the point where we had set up an arrangement for her to go live with family in another state. We arranged to ensure that she had drug treatment available for her. With all those things in place, we were able to provide her the best care that she needed, which included surgery. Because of that and because of all those efforts, she's alive today and still has her two kids with her.

Mark Briesacher, MD: Dean, you've been a hospitalist at Intermountain Healthcare for a while and been in different roles. This is not an unfamiliar story. After taking care of her, what were the next things that happened that you and the team continued to work on?

Dean Mayer, MD: I think what I recognized is that we were missing key parts to her care and patients just like her, 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. This patient was unique in the sense that she was quite passive and agreeable. That speaks to her vulnerability of influence in the community with friends that continued her drug use. We had to create a stronger bond with her family and away from the bond that she had with people that she shared drugs with. I'm really proud to have organized this team and looked at the different approaches that we needed to for this patient in dealing with not only her withdrawals from heroin, her infection that could've led to her death, the ethical implications of repeat surgery that the surgeons had difficulty with, and then finding a safe disposition for her away from the influences that created the recidivism and repeat infections.

In being able to draw all pieces of this together, and having a meeting with this patient and her family, and recognizing that she had an out, that really led to our need to look for an out for every patient because, frankly, a lot of these patients don't have family. They don't have friends that create a supportive environment, and they're alone. To be able to partner with a community facility that provides the addiction counseling and continued medical treatment that we needed to do outside of the hospital setting was critical.

Mark Briesacher, MD: Mike, maybe picking up on that, the drug treatment aspects of this particular type of case is sometimes the hardest to come by. There's stigmata that we've been working on for decades here at Intermountain Healthcare related to how behavioral health conditions are viewed. In these cases, the lack of access to drug counseling, to medications that can help people get through cravings, and the broader support that's needed to give them a chance to beat addiction, we will invest in the hospitalization, and oftentimes across the country these patients are then just discharged back to the same environment. Can you talk a little bit about when you came onto the team and began thinking about this as the psychiatrist here at Intermountain Medical Center, what were some of the most important things that happened?

Mike Coudreaut, MD: I think it's important to recognize that when people come into the hospital with a problem like this, they're not coming in for drug treatment. They're coming in because they're physically ill. There's an evolution of mindset that a person goes through when they get to the point where they actually want treatment. These are people coming into our arena, not necessarily seeking treatment for the drug problem. This person, for example, her lifestyle at that time was one where she had little support. Most of the people that she knew were other drug users. This was her community. We're taking them out of this community, putting them in this setting for a two-month period where their first problem is going to be the acute withdrawal.

When we started this, there was no consistent treatment of acute withdrawal. As we got together and talked about it, we decided to do opiate replacement therapy for these patients. Ideally, we would put patients on Suboxone. Unfortunately, many of these patients were being considered or surgery, and so putting them on Suboxone initially is contraindicated. For the most part, many of them went on methadone. Then they became patients that we could treat because, until they were more comfortable, these were patients that we couldn't treat, and they would leave the hospital, and we could never get to the point where surgery could even be considered. As we made them more comfortable here, that was great. My job was done for the most part. Then we continued to have this hole where, okay, they're in the hospital. They're here for two months. What next? How do they continue treatment?

Mark Briesacher, MD: What was the next thing that happened then?

Eddie Stenehjem, MD: I think the way we had been treating these patients was that we'd keep them in the hospital. We'd keep them in the hospital, give them their IV antibiotics because they didn't have a safe place to go. We didn't feel comfortable sending them home with a peripherally inserted central catheter where they had access to it. It wasn't safe for them. We were worried about them overdosing and leading to severe complications. We kept them in the hospital because that was what was best for the patient. But we soon realized that we weren't managing their addiction, and their infection was just the symptom of their underlying addiction. If we didn't address the underlying addiction, we were failing the patients. With Dean's leadership, we started looking at community partners. I'll let Dean tell us about our community partner with the VOA.

Dean Mayer, MD: We have guidelines and things within Intermountain that really push us to look at different options. We can't just focus on a facility or a single partner. I had to learn about requests for information, which really comes down to asking community partners that in this case providing addiction counseling within the realm of medical treatment was really important. I put it out to three or four different facilities, and the one that came out, the only one, was willing to do the things with us to continue medical care as well as, more importantly, provide them with the addiction counseling, and then furthermore, county funding to help them with legal issues, with family issues, with housing issues, with job issues. The Volunteers of America were willing to do all that with us. We had to create an environment under their guidelines and limitations of medical care so that they would allow our medical team to come in, which ended up being our home health agency, to come in and provide education and also introduction of these medications through the PICC line. In fact, they couldn't be there every day, so the scary part is we had to teach these vulnerable patients how to utilize their PICC line under supervision from the VOA. A little scary for us, but it has worked beautifully.

The other part of this that we had to draw in is how do we continue the opioid replacement that Mike and his team as the psychiatry consultative services provided here, how do we continue that in the outpatient setting. I found that Project Reality provides this for patients. What I found out is they actually travel to VOA on a daily basis, and they provide the methadone management, including reduction of dosing over a long period of time during their stay at the VOA and afterwards. That was a huge partnership especially, again, for these patients that were addicted to heroin, the opioid equivalent. That tied it all together. Being able to move our care into an outpatient setting where the care was much more complete and they got the addiction counseling so that we had, and will have, and continue to have, the ability to reduce the recidivism that happens with what we were seeing was repeat offenders or repeat medical issues.

Mark Briesacher, MD: There was a New York Times article recently talking about this problem. The one statistic that caught my attention was the fact that only 7% of patients who are intravenous drug users and who develop endocarditis and then are treated are still living 10 years later. How many people and families have you helped with this program?

Eddie Stenehjem, MD: We started the program in earnest in January. We enrolled our first patient into the VOA program towards the end of January. Since then, we have evaluated about 28 patients. We've pulled from Intermountain Medical Center, LDS Hospital, Alta View, and Riverton. Of those 28, we've gotten approximately 20 of them to the VOA to be enrolled in this program. Not all of them succeed. As Mike was saying, they come to our hospitals not seeking drug counseling, but they come because they're sick, and some of them are not ready for this. But we've gotten 20 to the VOA. We've touched those, and we've had many successes in that. We've gotten them out of the hospital and into an environment where they can succeed. Many of them have actually stayed at the VOA utilizing those services like legal and housing even after their infection has been treated. That just, I think, is a sentiment that it shows the success that we have with our community partners.

Mark Briesacher, MD: So, Dean, tell me a little bit about the role of our cardiovascular surgeons in this story?

Dean Mayer, MD: I think they play a huge role in our ability to evaluate the appropriateness of surgeries and sometimes facing the ethical dilemma of patients like we talked about earlier that have had a valve replacement and have gone out and used drugs and reinfected that valve. And to bring them into the team and express the gravity of the situation, not only to the patient and the family, but our medical team, to make decisions and important ones, whether we redo surgery. And putting a lot of responsibility on the patient to commit to changing their lives.

And that's what we did with our patient that we've talked about, and honestly, not every patient that is injecting drugs ends up with a heart infection, or a heart valve infection. There are spinal infections. Other infections that may be less dramatic and less life threatening. But the CT surgeons are a huge part of our team when we discuss where we go, medically/surgically, and psycho socially.

Mark Briesacher, MD: What are your thoughts on CT surgery?

Eddie Stenehjem, MD: CT surgery has such a pivotal role in this patient population. When you get an infection an already replaced valve, and most instances that is not curable with medical therapy alone. And CT surgery has been at the table with us from the beginning. They're willing to collaborate and listen to the patient, and we haven't set hard fast rules in terms of who is eligible and who is not for repeat surgeries. We really focus on the patient, and are they in a position where they are ready for another operation, and do they stand a chance of, not only curing the infection, but also curing their addiction. And, they've been incredible partners with this, and we look forward to continuing with them as we move forward.

Mark Briesacher, MD: So, thinking about the future ... we've got a really great program in Salt Lake County. How does this grow from this point?

Dean Mayer, MD: I think as we have this out there in extended communities as a program that provides care from start to finish, and creates a supportive environment as patients move out of our care process, we'll get more referrals from outlying communities. And we are more than happy to help them, not only move a patient to our program, but also help them develop their own program with the potentially limitations they have in their own community.

And, I think even beyond Utah, helping other medical systems create a similar team approach to a vulnerable population of patients.

Mark Briesacher, MD: Would they have to hire their own infectious disease doctor?

Eddie Stenehjem, MD: No. They certainly don't. We are in a position with our telehealth infrastructure to be able to offer infectious disease consultation outside of Intermountain Medical Center, and just about anywhere. We have fully staffed tele infectious disease program that can reach out and be the infectious disease content experts for all these communities. And it's leveraging what we have here centrally to really deploy local programs that we hope keeps the patient in their local environment engaged with their community, engaged with their family. That's the right place for them. And we see tremendous opportunities for growth. And like Dean said, we need to teach the rest of the US how we do it. And, we feel that we have a model that primarily treats the patient most effectively, but also makes good health economic sense, and I think it's up to us to be able to explain that and write about it.

Mark Briesacher, MD: And Mike, you mentioned that you had to figure out the standard protocol for treating patients during withdrawal. What are the next steps for that, working with the behavioral health clinical program at our other hospitals?

Mike Coudreaut, MD: Well I think the program travels. I have basically what they do at project reality and created a safe way to do that in the hospital. One that allows us to evaluate patients over time and how they tolerate the drugs, and then I encourage most of these patients to continue these for at least a year into their lives. But I think that's something that can be shared.

Mark Briesacher, MD: You know, when Intermountain Healthcare was formed in 1975, we received a charge to be a model health system, and certainly on this project, this is a tremendous model.

What has this meant for each of you on a personal level and professional?

Dean Mayer, MD: I'm going to say that on a professional level, Mark, the impact of teamwork to address the individual needs of patients that bring on challenges that sometimes we're not ready for, and to be able to insert the expertise and the specialties in each area to bring together a full service care model that continues into the community, to me has been just enlightening and brings a lot of pride for me.

Mark Briesacher, MD: Personally?

Dean Mayer, MD: Personally for me, being able to identify a problem within the hospital, and bring together this team and see the evolution of it and the success of it that fits into the Intermountain model. We can extend this into not only what we do locally with Intermountain but nationally to help programs just like you mentioned in the article that was struggling with it. When I read that, I look at, boy, we're three years ahead of the game in this. To share this program with people to bring together teams and focus on that will allow us to be successful not only locally but nationally.

Mark Briesacher, MD: Mike, how about you?

Mike Coudreaut, MD: At Intermountain, I've been here for 20 odd years, and our mission has always been to give the best care possible and the most affordable care possible. For every patient we have sent to the VOA, we have saved 25 days per patient of inpatient hospital care, which is a tremendous savings, and I find it very gratifying that we've been able to do that.

Mark Briesacher, MD: Of course, from our perspective as the safety net provider in this community, that just means that there are more resources available to take care of even more people who have this condition. I agree, Mike, it's tremendously gratifying. Eddie, how about you?

Eddie Stenehjem, MD: I think this touches on professional and personal. Professionally, it's a pleasure to work with a team that is so multidisciplinary. We've brought in people from antibiotic stewardship, from psychiatry, from hospital medicine, case management, risk, home care, tele-infectious disease—all of these people working together to solve a problem. It hasn't been easy. We've been fighting the good fight for now almost four years. It's been a testament to persistence, because this problem was not going away. As we know, the opioid epidemic still rages on. To work with a team that has such laser focus to be able to say, "This is a problem, and we can do better in healthcare," has been a joy. That's brought me incredible professional appreciation for this process.

Personally, the infectious disease consultant is in the position where they get to see the patient at their sickest. They see them in the hospital. They're dying. We get to see them get better with antibiotics, hopefully get surgery, transition to the VOA. They all come back to us to the infectious disease clinic for outpatient care, and we get them see them through the end when we get to stop antibiotics, and that they're cured, and hopefully that they are clean and sober. Every patient we see that has been a success, and there've been many of them, has been so personally gratifying, because you can see what the process did and how it was so worthwhile. All those years of frustration in dealing with this are gone, because you see what happens to these patients when they get housing, when they get reunited with their family, they get a job, and they're drug-free. It makes it worthwhile.

Mark Briesacher, MD: I can't thank the three of you enough. I wish I could thank everybody who's been involved in this work. I think you said it best, Eddie: To be persistent, to have that hedgehog mentality around a really tough problem, a tough social problem, a life-threatening medical problem, a lack of community resource problem, and to come up with this innovative approach partnering with Volunteers of America, partnering with Project Reality, I think this is an amazing story, and I'm so thankful that the three of you and everyone involved were thinking hard, working the problem, and always with the patient in mind, continuing to look for a better way to do this. I look forward to your next ideas. Thank you very much.