How an opioid addiction can eat your heart alive

JUDY WOODRUFF: While statistics about overdose deaths from the opioid epidemic continue to dominate headlines, other debilitating and costly problems have been creeping up in the shadows From PBS station ideastream in Cleveland, Kay Colby reports on an increase in deadly heart infections among I

V drug users, a little-known problem with big time consequences for individual patients and society as a whole It's part of our ongoing series America Addicted And a warning: Some of the images and photos you're about to see are graphic KAY COLBY: These images capture fallout from the opioid epidemic among people who are homeless in Chicago

They're part of a photo essay by Lloyd DeGrane published by "Belt" magazine in 2017 At times, heroin injected into the veins of users can lead to dangerous infections, like the one that killed this 34-year-old woman Almost 350 miles away, Cleveland Clinic surgeon Jose Navia is prepping for an operation to keep a similar infection from destroying the heart of a 31-year-old mother DR JOSE NAVIA, Cleveland Clinic: It's a very difficult case

Hopefully, we can do it in the right way And then we'd like to replace the valve, the aortic valve, and then repair or replace the mitral valve KAY COLBY: The human heart has four valves, including the aortic and mitral valves Each valve opens and closes with every heartbeat to control blood flow in certain directions Clumps of bacteria can attach to the flaps of valves, forming nodules of pus

DR STEVEN NISSEN, Cleveland Clinic: And so the valve is literally being eaten alive by the bacteria It eats away the tissue around the valve, and it is very difficult, almost impossible to cure with antibiotics KAY COLBY: Cleveland Clinic's head of cardiovascular medicine, Dr Steven Nissen, says, for people addicted to opioids, the pathway to deadly heart infections often begins with a dirty needle or polluted drug

DR STEVEN NISSEN: The heroin itself is not sterile You know, the addicts have learned — they will cook it They will use a flame to heat it up, but that doesn't generally sterilize it completely And so you're repeatedly injecting bacteria into your bloodstream

KAY COLBY: It's not long before Dr Navia confronts the full wrath of his patient's infection stemming from IV drug use All three flaps of the aortic valve resemble tiny pieces of Swiss cheese

DR JOSE NAVIA: This is another perforation It shouldn't be this way It should be completely closed here KAY COLBY: With the aortic valve completely destroyed, Dr

Navia opts to put in a replacement made of cow tissue After running a series of threads through it, he places it in position DR JOSE NAVIA: And this is the new valve KAY COLBY: With hands that mimic a keen knitting needle, he secures it in place

The cost of open-heart surgery like this can run over $100,000 Many patients come in with lots of complications requiring days or weeks in ICU Studies show cases of infective endocarditis, which is the medical term for infected heart valves, are on the rise among younger adults, mostly due to the opioid epidemic Three of the 21 occupied beds in the clinic's cardiac ICU are currently filled by endocarditis patients suffering from IV

drug use DR STEVEN NISSEN: That's very typical It can be more It can be less

But that's a pretty good average These days, that's what we see KAY COLBY: So, what is that telling you? DR STEVEN NISSEN: It is telling you that this is an epidemic that is just out of control KAY COLBY: The Cleveland Clinic says, in 2014, 10 percent of its endocarditis patients undergoing surgery were opioid-dependent

In the first six months of 2017, that percent was 185 Research elsewhere shows a similar trend A study at two large Boston found, between 2002 and 2014, their percent almost doubled The Boston study also found poor long-term results for those patients

Cleveland Clinic infectious disease chair Dr Steven Gordon says their research found poor outcomes starting about three months after surgery DR STEVEN GORDON, Cleveland Clinic: From 90 days to the six-month period, the risk of readmission or re-operation is 10-fold higher amongst the opioid use disorder patients with endocarditis that were operated on And we believe that is most likely due to relapse

KAY COLBY: Experts say those suffering from opioid addiction face high rates of relapse, which often means reinfected valves and repeat surgeries Many patients are on Medicaid or lack health insurance altogether DR STEVEN NISSEN: We have seen a fairly significant number of patients that have had not one, not two, but three or four heart valve replacements related to repeated use KAY COLBY: Bioethicist Mark Aulisio says repeat cases raise some thorny ethical issues

He and others argue addiction treatment needs to be part of the heart care protocol for such patients MARK AULISIO, Bioethicist: There's really got to be comprehensive care for patients who have this issue, because if there's not, you're going to put them through a lot of pain, some suffering, a difficult road, for little and in some cases maybe no benefit KAY COLBY: Gordon says the Cleveland Clinic now includes addiction treatment up front for endocarditis patients who use IV drugs

DR STEVEN GORDON: We want the addiction specialist up front, similar to what we would have our other subspecialist up front in the care for this patient, and if it's indicated, medication-assisted treatment and no barriers to getting started in the hospital, which is relatively novel, but a lot of hospitals are looking at that KAY COLBY: Public health advocates say these cases also point to the need for more harm reduction programs, like distributing clean needles, as well as devoting more resources to addiction treatment Again, Professor Mark Aulisio: MARK AULISIO: You don't have to care about any individual drug user one lick to know that it's in your interest for society to focus on prevention and harm reduction It's a lot cheaper to prevent endocarditis then to do a valve replacement

KAY COLBY: About three hours after scrubbing in, with the second valve repaired, Dr Navia weans his patient off the heart lung machine DR JOSE NAVIA: The heart is managed by its own And the two valves, the aortic valve that we replaced is working fantastic, and the mitral valve is repaired also

So the heart is getting a normal function And she's doing very, very well so far So, I'm very happy Came off the pump without any problem And so we will if she — the recovery, but I'm very happy with the results so far

KAY COLBY: While this surgery succeeded, big societal questions remain And, according to Steven Nissen, so does the human toll DR STEVEN NISSEN: If we don't cure the heroin addiction, then we haven't solved the problem And that's where we stand

The legacy of this is going to go on for decades It's a ripple effect And it keeps on growing KAY COLBY: For the "PBS NewsHour," I'm Kay Colby in Cleveland


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