**2. A brief examination of the literature**

There is an increasing body of literature prompted by the rapid increase of prescription and non-prescription opioid drugs in the United States that emerged in the 1990s and is at epidemic levels today. In 2016, 64,000 Americans died from drug overdoses, which was a 21% increase from the year before [2]. Some states are struggling more than others to combat this leading cause of death among Americans under age 50 [2]. Unfortunately, there is more discussion about public health and law enforcement interventions, rather than focusing on individualized medical care in persons who are in critical need of comprehensive therapy, which includes high-risk surgeries, detoxification programs, and extensive mental health care for chemical dependency among other related mental health disorders. Helping the addict is discussed less frequently as an important step to fight this epidemic [3], which is relevant to our ethical and social examination as to why we need to re-think the standards of medical care and treat patients holistically by incorporating mental health care into every aspect of their overall care. This is especially pertinent to the treatment of IE secondary to IVDU.

#### **2.1. Relationship of intravenous drug use and infective endocarditis**

life-threatening complications such as infective endocarditis (IE). These interventions, however, remain at the discretion of surgeons, and the healthcare team, whose treatment decisions are influenced by several medical factors, unfortunately not without bias. The stigma associated with substance use disorder is prevalent, especially toward IVDU, which leads to significant biases, even in the healthcare system [1]. This bias is heightened when IVDU patients require multiple or repeat valve replacement surgeries for IE due to continued drug

We explore various barriers when considering repeat heart valve surgeries, especially the implicit bias that can negatively influence the duty of physicians and their decision to provide comprehensive patient care. Patients who receive a valve replacement and continue to use illicit drugs intravenously, often return to their medical providers months to years later with a re-infection of their prosthetic valve; many of these patients have several medical comorbidities and require extensive care. The topic of multiple or repeat heart valve surgeries are the center of many ethical discussions due to the high mortality rates associated with both the inherent mortality from ongoing drug abuse and the risks of often complex and technically

This chapter examines the ethics of repeat heart valve replacement surgery for patients who are struggling with addiction, and the important factors that ought to guide health care professionals in making future treatment decisions. Considerations of justice, the fiduciary therapeutic relationship, and guiding ethical principles justify medically beneficial repeat heart valve replacement surgeries for IVDU patient populations. We will present and analyze two cases, which were presented to a hospital ethics committee, and provide justification for a narrative-based ethical approach to identify those factors for when patients ought to receive multiple heart valves and the conditions for pursuing this surgical intervention despite chem-

To better examine the ethical and social issues significant to discussions about heart valve replacement surgery among IVDU populations, particularly those seeking repeat surgeries due to chemical dependency relapse, it is important to understand the current climate in the United States with respect to IVDU and IE, as well as the need for comprehensive surgical and

There is an increasing body of literature prompted by the rapid increase of prescription and non-prescription opioid drugs in the United States that emerged in the 1990s and is at epidemic levels today. In 2016, 64,000 Americans died from drug overdoses, which was a 21% increase from the year before [2]. Some states are struggling more than others to combat this leading cause of death among Americans under age 50 [2]. Unfortunately, there is more discussion about public health and law enforcement interventions, rather than focusing on individualized medical care in persons who are in critical need of comprehensive therapy,

mental health care for patients who are committed to their recovery.

**2. A brief examination of the literature**

use, which can be quite costly for healthcare institutions.

challenging high-risk re-operative cardiac surgery.

ical dependency challenges.

134 Advanced Concepts in Endocarditis

With the rise of the opioid epidemic in the past few years, high-risk valve replacement surgeries have become a growing medical, financial, and ethical burden. Historically, IVDU represented a small percentage of patients with IE. In one study, the proportion increased from 14.8% in 2002–2004 to 26% in 2012–2014 during which time, heroin use doubled [4, 5]. Today, approximately 11% of IVDU are at risk for developing IE [6], which is characterized by infection of the inner lining of the heart, leading to the growth of vegetation on heart valves that disrupt the ability to pump blood. Overall, IE is an extremely morbid disease: in-hospital mortality rates range from 11 to 26% with an estimated 5-year mortality of up to 50% [7]. Complications include heart failure, valve insufficiency, embolic strokes, and intracerebral hemorrhage. IE secondary to IVDU is most commonly caused by bacteremia from *Staphylococcus aureus* and *Enterococcus faecalis* that are abundantly found on the skin and gastrointestinal tract, or by particulates in illicit drugs that cause micro-damage to tissues as they circulate [8, 9] following injection. Treatment is often sufficient using high-dose antibiotics, but 60 to 70% of severe cases require surgical intervention [4].

Studies have shown that patients with IE secondary to IVDU are younger than patients with no IVDU and more likely to be young Caucasian males, with some regional variability among populations [4]. The average age of patients who suffer from IE secondary to IVDU is 30 years old, and 90% of them are heroin addicts [7, 8]. Approximately 75% of individuals admitted to treatment for heroin abuse or dependency reported using injection as the primary method of drug use [10].

Despite IVDU representing a significantly younger patient population with less cardiovascular and comorbid risk factors, long-term outcomes are compromised by reinfection [4] and continued drug abuse. A patient who receives a valve replacement yet continues to use intravenous drugs is likely to re-infect their bioprosthetic or homograft valves, requiring additional valve replacement surgeries. However, such treatment opportunities may not be offered to this patient population due to high mortality rates. For example, studies have found that patients who resume IVDU after their initial valve replacement have high mortality compared to patients who abstain from drug use after their surgery [11]. A patient who resumes IVDU may get an extra 1–5 years of life out of their new valve rather than the 10–15 years of life that a new valve (mechanical or biological) can give without IVDU. Such decision-making must also be done in the setting of the overall poor and limited (but somewhat incompletely defined) life-expectancy of the habitual use of IV drugs.

#### **2.2. Factors contributing to stigma and the refusal of care**

In general, many surgical professionals identify repeat valve replacement surgery as nonbeneficial for patients with IVDU, and thus, refuse or are reluctant to offer this procedure or refer patients to other surgeons who are willing to treat this patient population. Even when the valve replacement surgery may provide some benefit and give a few more years of quality life for patients, surgical professionals and the healthcare team may feel as though the financial burdens to patients and healthcare institutions is a reasonable justification for not replacing infected valves. This is especially true given the high relapse rates for IVDU and readmission with active IVDU. In addition, because the IVDU patient population contributes to increased unemployment and reliance on publicly funded insurance [12], some health care professionals may feel as though they have a duty to the community by not prolonging the lives of patients with IE secondary to IVDU, and thus adding additional financial burdens for communities and an already resource-limited health system.

clinical, psychosocial, and legal outcomes (e.g., improved medical compliance, reduced recidivism in drug use and criminal acts). One study found that only 7.8% of patients treated for IE were discharged with plans to receive medication-assisted treatment during the 10-year period of the study. In that same study, 25% of patients were readmitted with active IVDU [16]. Aggressive treatment for IE, including antibiotics and valve transplants, is neither effective nor advantageous without targeting the underlying addictive behaviors that contribute to

The Ethics in Repeat Heart Valve Replacement Surgery http://dx.doi.org/10.5772/intechopen.76844 137

Addiction treatment, particularly for opioid users, is limited by factors that are beyond the control of physicians and drug users who may be willing to seek recovery. A study published by Jones *et al.* in 2015 reported that nationally, 96% of states (48 out of 50) had lower opioid treatment program capacity rates than their corresponding opioid abuse or dependence rates. The study also reported that 38 states had over 75% of their opioid treatment programs operating at an 80% capacity or more [17]. These numbers are indicative of a severe national shortage in treatment options, which could in part explain the ongoing struggle in IVDU achieving

Furthermore, little theoretical work has been done to identify the complex ethical issues surrounding this IVDU patient population who qualify for valve replacement surgery but who may be denied this life-sustaining intervention due to a number of factors including, but not limited to, financial cost, perceived poor quality of life, suspected non-compliance in postsurgical care and addiction treatment, and social worth. This chapter aims to start closing these gaps and to provide guidance to surgeons and healthcare teams when confronted with

Thus, through the presentation of two cases of IE secondary to IVDU, we will identify the medical, social, and ethical issues, recommendations for whether we should provide repeat valve replacements, and how we ought to treat patients who are struggling with mental health issues, including, but not limited to chemical dependency. Our case analyses will also identify the limits of justice and the duty of health care professionals in providing repeat heart

The following two case presentations are based on actual patients with identifying information removed so as to protect their identities. These cases were presented to an ethics committee for an initial recommendation; however, the analysis and discussion presented here extends beyond committee consultation or even those guiding ethical principles that contribute to decision-making and resolution. These cases reveal a need for a narrative ethical approach to best understand individual patients and their medical, psychosocial, and valuebased needs from diagnosis through recovery. The cases presented in this chapter are montages of health care team members' stories about their interactions with patients through medical evidence, patient interviewing, and clinical observation. However, there is an equal need for the medical team and the patient to co-author or construct a joint narrative of illness and medical care [18, 19]. These cases, however, do represent the multiple voices of the

poor health outcomes and mortality.

or maintaining their recovery.

valve surgeries.

**3. Case presentation**

difficult medical, social, and ethical dilemmas.

Smyth et al. (2010) conducted a prospective study of patients who were dependent on opioids and admitted to a residential chemical dependency service for treatment. The authors found that 91% of 109 patients interviewed had relapsed; 59% relapsed just within one week of discharge [13]. Those who had earlier relapse were characteristic of our patient population; patients are younger in age, have a history of IVDU, did not complete the recommended length of time in the addiction program, and did not enter in or commit to aftercare programs. The authors also found that delayed relapse occurred among those who completed their entire program, as well as those individuals who were in a relationship with an opiate user, which was an unexpected finding and deserves further research [13].

Furthermore, given the significant rise of IVDU with the opiate epidemic in the United States, further research on relapse is needed, including the multitude of factors that contribute to relapse. Without addressing the factors that contribute to relapse, the rate will continue to rise, perpetuate stigma, fuel healthcare professionals' reluctance to provide multiple heart valve replacement surgeries, among other medical interventions. A study in China examined heroin addiction relapse and the effects of detoxification medications (methadone) combined with psychological counseling and social support measures, which were found to be essential to ongoing recovery and reduction of relapse rates along with patient compliance [14]. Additional studies have found that patients who recur to IVDU after the initial valve replacement procedure have very high mortality compared to patients who undergo rehabilitation [15].

From a medical perspective, the relationship between IE and substance use disorder is no different than nephropathy and diabetes, coronary artery disease and smoking, or the countless other chronic medical problems that are worsened by "life-style" choices. However, the negative connotations and stigma associated with IVDU lead to patients being treated differently in the health care system and among physicians, who deny life-saving care and devalue their patients as persons in need of advocacy and support to combat their addictions.

#### **2.3. Gaps in the literature**

Unfortunately, little research has been done on the value of extensive psychiatric and behavioral health interventions prior to, during, and following surgical treatment and the overall clinical, psychosocial, and legal outcomes (e.g., improved medical compliance, reduced recidivism in drug use and criminal acts). One study found that only 7.8% of patients treated for IE were discharged with plans to receive medication-assisted treatment during the 10-year period of the study. In that same study, 25% of patients were readmitted with active IVDU [16]. Aggressive treatment for IE, including antibiotics and valve transplants, is neither effective nor advantageous without targeting the underlying addictive behaviors that contribute to poor health outcomes and mortality.

Addiction treatment, particularly for opioid users, is limited by factors that are beyond the control of physicians and drug users who may be willing to seek recovery. A study published by Jones *et al.* in 2015 reported that nationally, 96% of states (48 out of 50) had lower opioid treatment program capacity rates than their corresponding opioid abuse or dependence rates. The study also reported that 38 states had over 75% of their opioid treatment programs operating at an 80% capacity or more [17]. These numbers are indicative of a severe national shortage in treatment options, which could in part explain the ongoing struggle in IVDU achieving or maintaining their recovery.

Furthermore, little theoretical work has been done to identify the complex ethical issues surrounding this IVDU patient population who qualify for valve replacement surgery but who may be denied this life-sustaining intervention due to a number of factors including, but not limited to, financial cost, perceived poor quality of life, suspected non-compliance in postsurgical care and addiction treatment, and social worth. This chapter aims to start closing these gaps and to provide guidance to surgeons and healthcare teams when confronted with difficult medical, social, and ethical dilemmas.

Thus, through the presentation of two cases of IE secondary to IVDU, we will identify the medical, social, and ethical issues, recommendations for whether we should provide repeat valve replacements, and how we ought to treat patients who are struggling with mental health issues, including, but not limited to chemical dependency. Our case analyses will also identify the limits of justice and the duty of health care professionals in providing repeat heart valve surgeries.
