Okay, good afternoon, everybody. Welcome to today's webinar on Bugs and Drugs, Case-Based Pearls for Addiction Consultants Treating People Who Use Drugs Hospitalized with Infections. My name is Julie Kimmick, and I'm your moderator for this session. Today, we have Dr. Aisha Appa, who is an Assistant Professor of Medicine in the Division of HIV, Infectious Disease, and Global Medicine at the University of California, San Francisco, where she completed fellowship in both addiction medicine and infectious diseases. Her research focuses on integrating HIV care with substance use disorder treatment, and she's currently funded to study overdose prevention and contingency management for stimulant use reduction and antiretroviral therapy adherence support in HIV care delivery settings. In addition to her clinical work on both the infectious disease specialist team and the addiction medicine specialist team, Dr. Appa directs a status-neutral clinic for people who use drugs, providing low-barrier HIV, infectious disease prevention, and treatment within the Ward 86 HIV clinic at Zuckerberg, San Francisco General Hospital and Trauma Center. She also serves as a staff scientist at the San Francisco Department of Health's Center on Substance Use and Health. So welcome today, Dr. Appa. Thank you so much, Julie. I am thrilled to be here with you all. I really appreciate the introduction and just love working at this intersection of bugs and drugs, and I'm very excited to share with you a case-based approach to thinking about caring for people who use drugs hospitalized with infections. So for context, this talk is based on an article that I wrote with colleagues in clinical infectious diseases that you can see here that's sort of focusing on harm reduction and shared decision-making for this population, and we will walk through four cases, four patients that we've seen and maybe familiar stories for you, again, that sort of live in this overlap space, and I will hopefully cover common clinical situations that you find yourself in, and please feel free to put questions in the Q&A. Julie can stop me, or we can certainly, I'm going to try to keep an eye on the time, certainly hope to have time at the end for questions and discussion. So without further ado, I will move on to our first case. We have a patient with opioid use disorder who would like to be discharged home with IV antibiotics, and you are helping the team sort through what is possible. So a patient that you're seeing in the hospital is a 35-year-old woman with opioid use disorder in remission on methadone who's hospitalized with a fever and a dental infection that's found to have strep mydysbacteremia. She describes that she had been feeling unwell for about a week, had a fever, noticed purulent drainage from one spot of her gums, and trying to sort of avoid the hospital, took her friends doxycycline for a few days, and then things just sort of progressed and felt unwell, so she came into the ED. She previously injected drugs last over a year ago. As I mentioned, she's on a stable dose of methadone, and objectively, she has a normal transthoracic echo that's good quality, and her blood cultures clear really quickly, and she gets her tooth pulled. The patient is a mother and would like to get home to her kids, and her primary team, the medicine team, is considering discharging her home on IV ampicillin sulbactam, and they ask you as the addiction medicine consultant, you know, is this patient safe for home-based what's called OPAT? You might be familiar with this acronym or not. Outpatient parenteral antibiotic therapy is a term ID folks use and you'll see around, and so you feel free to put your answers in the chat, or just think about where you're aligning. You think, no, I'm not going to send this patient home. She has a history of injection drug use. No, she's misused other antibiotics prior to admission, so I'm not really sure about this idea of sending her home without, you know, more supervision, and then yes, if the ID team can make it happen to do this outpatient IV antibiotic therapy, and then D is a maybe, and I'm seeing a vote, a vote for C. Thank you, and I will share what I think the best answer is, and I also would pick C in this setting, but D is another great choice, and let's talk about these answer choices. So I realize I'm sort of preaching to a choir here around option A. You're, I think, a group of people used to really knowing your patients well and knowing that a label of PWID that doesn't have to define someone in the chart or in real life, and in reality, I think prior or even current injection drug use is not a clear contraindication to OPAT. I think conversely, it doesn't mean that it's right for everyone either, as you might have seen in your practice, and so really having that conversation about what does the patient want? Are they going to find this triggering? Is this actually something that's the right risk-benefit ratio for them? That is, and that's always the right first step. One self-promoting plug for this, a little bit of a summary of the evidence that Josh Barocca, a colleague of mine, and I wrote that tries to pull together, like, what do we know about discharging patients home with a PIC? And so if you're asked this question as an addiction consultant and are trying to say, like, well, this is what's out there, that's one reference that can help you sort of walk through what we know, and essentially, there have been hundreds and hundreds of cases in aggregate of successful outpatient antibiotic therapy delivered to people who inject drugs, people who use drugs, people with substance use disorders, and so it's really about finding what's right for your patient. Option B, you know, why don't I think it's the right answer to be a bit judgy about our patient using our friend's doxycycline? Well, again, as you might have seen, people who use drugs have repeatedly faced discrimination from medical settings and others, and so we know from qualitative data, and you may have experienced this anecdotally, that it's not uncommon for patients to get antimicrobials from loved ones, from community partners, or even veterinary stores to avoid this, what can be traumatic hospitalization. So just because someone took some antibiotics before the hospitalization doesn't mean anything about, you know, misuse, and it's important to, I think, on the flip side, if you're, say, medically caring for the patient, consider that pre-hospital antibiotics might have been a part of their life. One, I think, you know, that brings us to our option C and D, and thinking about your experience advocating for your patients about their antibiotic decisions. You know, our webinar format, like, isn't the best with this big group to maybe unmute yourselves, but please feel free to add any comments in the chat if you have any particularly, you know, either good or challenging interactions in which you had to advocate for your patients around their antibiotic choices. Would love to see it and hear it and sort of use that as we continue to move on in the next hour. I'll keep the chat open, but yeah, please feel free to share. I think that another common request that I end up fielding either when I'm wearing my addiction medicine hat and attending on the addiction care team or when I'm on the ID service is this idea of, like, what about safety of OPAT in a patient with a history of drug use? What do we know about that? And I think that we can break that down in a couple of different ways. There are some risk assessment tools for OPAT in people who use drugs, and then a few sort of cool multidisciplinary models of evaluating antibiotic decision-making, and then we'll talk about shared decision-making a bit more at the end. So let me just share a couple of these tools in case you find this useful and want to build this into your practice. So some colleagues at the University of Alabama found that discharging people with mild risk as assessed by this tool here on the left that looked at IV antibiotics and sort of addiction features was associated with a reduced length of stay. Not surprisingly, they were letting people, sort of facilitating people leaving the hospital without an increase in readmissions, and that's phenomenal. So essentially they looked at some factors that related to potential stability of the person and factors that you might imagine predicted success as an outpatient completing antibiotic treatment. I will say that this was expert opinion of the providers in this clinical context in Birmingham, Alabama. So how common it is to see folks with dual diagnoses or a history of trauma in my practice at San Francisco General is maybe different than in different areas of the country. And so I found myself thinking, well, I think all my patients would score at least moderate, which is four to six on this scale. So how would this work for me? And we don't really know, but I do, I think, want to share that this was lovely work that showed that we can employ some form of risk stratification and people can do well with home IV antibiotics. Sort of getting to our second bullet, there are a few different groups around the country that have implemented multidisciplinary case conferences to discuss optimal antibiotic strategies. And at Oregon Health and Sciences University, they have a really wonderful model that brings together the primary team, a case manager, the addiction consult team, infectious diseases physician, and the OPAP program's nurse who leads this conversation. And you can sort of see this script here on the left that sort of goes through an ethical framework of how to think through options for the patient. They noted in their description and sort of publication of this protocol that these conferences took about 28 minutes on average and ended up facilitating higher rates of completion, antibiotic completion, and fewer losses to follow up with similar readmissions. So there's always room for improvement here, but I think that was another sort of inspiring resource that is instructive. And like I mentioned, we'll talk more, a little bit more about shared decision making as we move through our next few cases. Let me just really quick see if I can pull up something from the Q&A. Oh, and then I'll just answer a question in the chat. What level of evidence is there for IVAT? And I think if referring to that specific questionnaire and using that to predict outcomes in sort of successful completion of antibiotics, it truly was, there've been two small cohort studies that have been published in the last few years in open form infectious diseases and clinical infectious diseases that sort of looked at readmissions and length of stay, like I mentioned. So it's not sort of a, it's on the order of pilot studies. So if you're thinking of implementing your own or thinking about your own, you can certainly either be inspired by that or create your own is that there is not sort of one standard of care in terms of risk assessment tool. Um, so what happened with our patient? Um, she, um, um, uh, you know, so the question was, can she go home on ampsylbacter learning point? That is, um, a Q six hour medication. That is not a great one for someone to leave the hospital with. And so infectious diseases and addiction medicine, um, talked with each other, discussed options alongside that patient and recommended that she, um, do go home with daily ceftriaxone. Um, that, that is a pretty, pretty easy push, um, 30 minute administration once a day, um, and would be compatible and not interfere with her getting to methadone clinic where she's going daily still, um, case. So case two we'll move on, um, is a patient on treatment for endocarditis who, um, also is incident OUD, um, feels, feels ready to leave the hospital and we're re-evaluating what, what we can do. So our patient is a 44 year old man with untreated opioid use disorder, housing instability, who's admitted from jail with MRSA mitral valve endocarditis. Um, he has a half a centimeter vegetation on, um, trans esophageal echocardiogram gets started on vancomycin that he's getting three times a day. Um, he has, um, positive blood cultures for, for, for three days, and then they subsequently cleared on that vancomycin antibiotic. Um, and he gets started on methadone and is now current now on 50 milligrams and has been in the hospital for four weeks, um, completing, um, treatments with, um, with vancomycin with plan to treat for, for six weeks. So the primary team asks you, um, uh, the patient wants to leave. Are you okay with whatever oral antibiotic regimen we come up with? Um, and you might be asking yourself, like, I'm an addiction consultant. Why, why are you asking about antibiotics? Like what, what does it matter? Um, and, uh, and so you might select E here. Um, but, um, I'm curious whether folks think like, a, you don't know, I would vote for, um, for the patient sticking it out for the last two weeks in the hospital. Um, B let's go with some, um, bioavailable options, ciprofloxacin and rifampin. Um, there's some evidence for, for that being effective, um, as oral treatment for endocarditis. Um, C is dalbovansin, um, a, um, a long acting injectable, um, medication and D I want more information. I'm seeing some great, um, awesome. Thank you for, for throwing this in the chat. Um, uh, but if someone's interested in, in sensitivities, what do we know? Um, this MRSA is susceptible to, and then, um, yeah, do, do I need to know? Um, so I see a vote for C and then some Ds. Great. Um, I agree with you all. Um, let's talk about, let's go through our answer choices and, um, uh, and, and talk about why we're here. Respect. Oh, yeah. And someone's saying E, why do we need to know? Okay. So let's first start with sort of a few, a few sort of key pillars in this domain is I think one, um, one important take home is, is that based on many, a retrospective study and one particularly well done one here is, is, is what I'm highlighting. We know that some antibiotics are better than no antibiotics at time of self-discharge. So I'm, you know, I'm curious what each of your practice settings is like, but I will say that at San Francisco general, um, you know, when I started fellowship training in 2018, um, it was very common. We, you know, when, when folks left the hospital, there was sort of a prevailing attitude that, you know, IV was best. And, um, if they couldn't do IV, maybe they'd come back for it. We're not going to work really hard to get them oral antibiotics. Um, if they weren't able to complete, complete their IV treatment. Um, and, and I think what we've learned with, um, a combination of, of retrospective data that I'm showing some here and some, um, really, um, large randomized clinical trials that look at certain oral antibiotics that are, um, highly bioavailable and, and, and sort of equivalently effective for, um, a number of serious infections is that oral antibiotics, um, as makes sense, like can work really well, particularly in this step down context. One of my, um, mentors used to say, like, um, the bugs don't know how they're getting killed if they're getting enough antibiotic in that space. And so, um, what, what this study looks at is some colleagues at Wash U found that people who injected drugs, who did not receive oral antibiotics at time of, of self-discharge, um, um, had, had double the hazard of 90 day readmission as, as compared to people who injected drugs, who, who did receive, um, oral antibiotics and the people that were, there was no statistically significant difference between the people who completed their inpatient IV antibiotics versus, um, partial IV and partial oral. Um, and, and I appreciate the, um, someone mentioning in the chat when, yes, when, you know, uh, you know, up to a quarter or more of, of, of your patients may, um, be directing their own discharge. Like you, you do need options and to, to sort of work around where they'll be. So the reason why I would argue that, um, E is not the best answer is that one, the one thing that I would sort of be alert and attuned to as an addiction consultant to is when your ID friends or a primary team want, um, want to start rifampin. Um, rifampin, um, is, um, associated with a 50% incidence of clinical opioid withdrawal in people stable on buprenorphine, and that we know, and I'll share some methadone data on the next slide, and we know as like a really potent CYP3 to A4 inducer, it's like basically like slamming on the gas of metabolism. You're just people, you're like chewing through, you're methadone or you're bup. And so for some individuals, their methadone levels or buprenorphine levels can fall and lead to really clinically significant opioid withdrawal and then destabilization of their MOUD, of their addiction trajectory. And so it's important to, I think not only if possible, consider as I highlighted on this slide, rifabutin, which is, can be a CYP inducer, but just less so, and is less, as demonstrated in this study, sort of less clinically likely to cause a clinically significant interaction with methadone or bup. And if rifabutin isn't possible, then it involves a lot of sort of clinical expectant management with your patients. So our patient was on methadone, like what's the latest there? Honestly, there has not been, there is not a latest, there have not been studies that have been done recently. There is a very old study from 96 here, in which about 20% of the participants had a decrease in their methadone, sort of over 30% after a couple of weeks of rifabutin. And sorry, and that like is, or I'll say rifampin can reduce methadone between 30 to 70%. And so those, I think that trying your best to avoid rifampin is possible. And then for rifabutin, if somebody is on methadone, I think counseling them that it may lead to opioid withdrawal and your methadone dose may need to be adjusted, or we might need to stop the rifamicin is something that's important to do. And I will, I'll leave it there. Happy to take questions about that at the end, if we have time. And then I think the last, you know, related note here is, you know, for our patient, we're thinking about someone who has newly diagnosed opioid use disorder, got started on methadone in the hospital. And that's something that has changed over the past decade, like how commonly folks were getting started on methadone in the hospital and connected to the outpatient setting has really changed. And I think addiction medicine consultation has been, it's sort of a key factor in driving reductions in mortality for some of these hospitalized patients. And so this was a nice study out of Pittsburgh in which they did a propensity matched analysis of folks that were seen by addiction medicine and people that were not. And showed a reduction in 90 day mortality. And why, I mean, I think, again, this is, you know the answer to this. We know that methadone and buprenorphine are associated with 50% reduction in all-cause mortality. So when we have a service that can not only deploy those medications, but also work on increasing them to an appropriate treatment dose and, you know, being mindful of drug interactions and sort of helping, you know, guide the patient from outpatient, inpatient to outpatient, all these things, all these things save lives. So that, I think that was a key takeaway of this study in the slide. I think one other thing that I thought I'd share that again, may be happening variably in each of your settings is that not only is it methadone being started, but I think particularly in the era of fentanyl that we're all living in, you know, we're seeing certainly here, you know, average doses of methadone that were treatment doses may have been 80 milligrams before 2018 in California. And now we're seeing a commonly push up to 120, 150 and that's average, so and beyond. And alongside that, I think figuring out as we titrate methadone or buprenorphine to a treatment dose, how are we caring for someone in the hospital and how do we address their opioid debt? And so this is an example of an order set that is for ordering short acting opioids for opioid withdrawal. And this essentially helps primary teams recognize that they're caring for somebody with opioid tolerance and sort of start here as you can see at higher doses than a naive person. So instead of like five milligrams of oxycodone and, you know, 0.2 of hydromorphone, folks are getting these higher doses here, 20 to 30 of oxycodone and, you know, one to two milligrams of IV hydromorphone. So what happens with our patient? After four weeks in the hospital, he is ready to go. And, you know, you end up saying, you know, I'm okay with many an option, just not the Cipro and rifampin option, please. The ID team ends up arranging for dalbovansin, which is the long acting injectable lipoglycopeptide, which is essentially a cousin or sibling of vancomycin. You can think of it as essentially long acting vancomycin that has a half-life of two weeks. And when administered with two doses one week apart can last for as long as six weeks and emerging data are suggestive that it is sort of as safe as used in step down as is completing a full six-week course in antibiotics. So that is what our patient ends up getting and as well as addiction follow-up. Our third case is a patient with stimulant use disorder and negative bacteremia who is deciding to leave the hospital pretty early on in their stay. So this is a 26-year-old woman experiencing homelessness with stimulant use disorder admitted to the intensive care unit with septic shock and serratia bacteremia. On their second hospital day, they improved really rapidly on empiric vancomycin and piptazo, piperacillin tazobactam, broad spectrum antibiotics. And then the next day they're transferred to the floor still on the piptazo while the serratia is that we're waiting susceptibilities. And one of the medical students has a really, really wonderful detailed conversation with a patient about how they're injecting. And the patient shares that they're using non-sterile water and often needing to reuse needles. And she stays in the Bayview-Hunters Point area of San Francisco that has been a sort of desert with regards to access to syringe services. And the primary team says, I wanna get your help. This patient's gonna leave in two hours. Is there anything we can do to prevent her from leaving and support her use disorder and health before she goes? And you might have fielded calls like this and might've felt like, what magic can I do for stimulants in two hours? Like, I'm sorry, but like, well, what am I gonna do for this person? And what I'd say is like, as in our prior cases, there's, we'll sort of go through this in three steps. One part that I won't go into, they don't have a separate slide on, but is sort of optimizing treatment of current infection. I think we often, as the addiction consultants, end up playing this role of somebody who sort of has the privilege of really getting into somebody's life and understanding their experience. And so, are there ways that we can sort of lower the barriers for her to complete her treatment? You know, can we encourage that primary team to, you may not be able to say, no, I don't have a magically, you know, as potent FDA approved medication for stimulant use disorder, but can I work on getting her oral antibiotics that are in hand before she goes? That sort of thing. So I think that there's, that is one force of advocacy that we can have. And then the other bit that is not done as commonly in hospital settings as we should do is having a conversation about secondary infection prevention. The, you know, we learned in this case that the patient was not able to access a supply of injection equipment that she could use as a single use, a single use supplies and dispose of. And she was having to reuse and sort of use less safe versions of her supplies. And this is a nice article that takes this concept that's called the six moments of infection prevention, which is used in sort of quality improvement in infection prevention in the hospital, but sort of translates that into IDU. And it sort of starts with, you know, the needle and sort of expands out from there as you can see in the different like rainbow colors. And so often I think like, you know, something that it's easy to fall into a trap without asking is like, oh, do you use clean needles? And not only is that, you know, subject to sort of like social desirability bias or confirmation bias, people are just saying like, yes, but needles are just part of the needles and works that can transmit both, you know, bacteria and viruses, fungi, et cetera. So I think that, you know, that we have depicted here, again, this needle, the water, saline, and or acidification agent like the vitamin C or lemon, which may be the less safe option that can confer cannidal infection. We have the spoon or the cooker that can also be, particularly when there's some blood products in the cooker can harbor HIV and hepatitis for weeks actually on sort of used cookers or spoons. There's the filter pictured here that people draw up through. And then in blue down below, there is the unclean skin. So the step that when I talk with my patients about, you know, just like, tell me a bit more about how you're using. I often hear of folks like not necessarily cleaning their skin and we see so commonly our skin flora that cause these invasive or deep-seated infections. And then six is talking about a contaminated needle after filling the syringe from like licking their needle that can be habitual for some people. I share all of this, which again, you know, but to introduce the idea or to reinforce if you're doing this in your sites that, you know, even when it feels like you may not have a treatment option that is as effective as you'd want it to be. For our patient that, you know, we're talking about in this case, we did learn how she's using. We have an opportunity to either provide safe consumption, harm reduction materials in the hospital or connect her with a place where she can reliably receive these to optimally prevent another infection like this in the future. And at San Francisco General, we piloted and continue to give out safer injecting and smoking equipment alongside naloxone and fentanyl test strips at discharge for people. And this required a lot of sort of advocacy on one of the directors of our services, part with a hospital, but in a really nice paper written by a formal medical student, sort of interviewing both patients and staff about how it made them feel. You can see here that people describe that having, there were sort of two, lots of ways in which this really added to care. You know, patients mentioned, I felt a big relief being able to access these services, particularly in a place that is such a, in which there's such a focus on stimulants like in our city here in San Francisco. And then it was a really an opportunity as hospitalizations often are, is like a reachable moment. It was an opportunity, this patient sharing here in Spanish that he hadn't been able to learn much about harm reduction in the past. And this was, again, an opportunity to reach people. So I think that something I'll just add anecdotally is that I think some people worried about, you know, were staff going to be interested in this or not, or feel like this is outside their scope, burdensome, not like this. And I think conversely, what I've heard from staff is that they really felt like, oh, I felt empowered that I had something to give, to talk about with patients, to promote their health and keep them healthier. And that was really gratifying. So that has been really a boon. And then the last piece here is thinking about for our patient HIV prevention. So we talked about how due to limited access, she was reusing her needles. And one question that I will pose to you all is what proportion of people who inject drugs in San Francisco do you think are on pre-exposure prophylaxis for HIV? Is, you know, San Francisco is a high density of HIV providers, HIV services, you know, syringe access programs. Is it, are we at C, 20 to 30%? B, 5 to 10%? Or A, less than 2%? People want to sort of throw any guesses in the chat. I see a B vote. And a lot, yeah, a lot of Bs and some, a mix, excellent. Really great. B, unfortunately the answer is A, less than 2%. So in a NHBS survey that I have data specifically about San Francisco County and I think it'd be interesting to know what these data are in any of the locales that you're practicing, the PrEP cascade is really fascinating. So when you look at the number of people that are people who inject drugs, they're even aware of PrEP as a strategy that you can take a pill and, you know, one day or now an injection to prevent HIV. Almost half of people didn't even know that this was a possibility. And then when, with regards to like our even use PrEP, let alone are still on PrEP, that currently in San Francisco is that one and a half percent of people who inject drugs estimated. And I think that this, is just like an unfortunate piece of data fitting with another piece of data, which is that we are seeing in the city increasing new HIV infections among people who inject drugs. Interestingly, sort of epidemiologically in San Francisco, we are also seeing a strong shift to smoking drugs from injecting. So a lot of our incident cases are either folks with sexual risk or a combination of sexual and injection drug use. But despite even that epidemiologic shift in how people are using, we're still seeing these rising numbers in people who inject drugs. And so I think that what, oh, and this is, sorry. And it is like primarily methamphetamines being injected also associated with incident HIV. So where can we move the needle? I think that at minimum, what we can do is increase awareness about PrEP. So I think there's often a really reasonable debate around, say you're caring for a patient and experiencing homelessness who has heart failure and stimulant use disorder. Like, they're barely taking their goal-directed medical therapy or they're not. Am I really gonna start prepping that person? Maybe not. Maybe it's not the right thing for every patient. But at minimum, I think we can work on this awareness gap and then work toward connecting people, giving people options. So I think I always share a story that I saw a patient in the hospital this past year who was in his mid forties and hospitalized with this really gnarly, actually like H-flu multifocal abscesses presentation. And he, when we were talking about PrEP he injected methamphetamine and sort of didn't always, sometimes shared his needles and works. He was like, what? There's a pill to prevent HIV? Like, nobody knows about this. Like, I gotta tell my friends. And so it's like, when you have that moment, when someone, it's like, it truly is, when you find somebody who wants to be empowered by that strategy to protect themselves, that's fantastic. Again, may not be right for everybody, but I think important to empower our patients with choice. And so what happened in our patient's case, we as the addiction medicine consultants talked with the primary team and said, we'll do our best to see her before she goes in two hours and get her safe consumption supplies. And then sort of arching back to moving the needle where we can advocate. We also asked the primary team, can you ensure that she gets ciprofloxacin to bedside and confirm her contact information, very basic sort of things to help make that transition to the outpatient world easier. And ask her what she knows about HIV PrEP. Like again, use that reachable moment. And that is our third case. And then I'll finish with our fourth case and see what questions people have. So our fourth case is a patient who's using drugs while receiving IV antibiotics. This is a 52 year old man experiencing homelessness with opioid and stimulant use disorders who was admitted about a month ago with MSSA prosthetic valve endocarditis. He was admitted, started on vancomycin and then switched to the fazolin and rifabutin as well as buprenorphine for his OUD. Often we entertain giving people gentamicin. He didn't get it given he had some sort of elevated creatinine on admission. His cultures were clear after the fifth hospital day and other than some septic emboli to the lungs, he's otherwise doing okay. He's discharged to our internal skilled nursing facility to continue his two antibiotics and his buprenorphine. And then the primary team calls you because the patient was caught with injection paraphernalia in his room. And they ask, do we need to take out his PICC line? What do you think about that? And the answer to this is that it's complicated. And I think this case as well as the first case and really honestly, all of them and many hopefully cases that you're engaging with involve applying some sort of shared decision-making to infectious diseases care. And I think that's really, I'm saying this about this overlap space of infectious diseases and addiction medicine, but it also can apply to medications for substance use disorders as well. I think this is a really nice framework that, where do I have the citation? Oh yeah, here. Dr. Thakkarar in Maine presented and has sort of used in clinical practice and evaluated. And it involves sort of five basic steps that may sound familiar in things, places that you, in medical school, you've learned framework of ask, tell, ask, or sort of eliciting the patient's opinion or understanding of the situation. And then getting sort of assessing where they are, sharing your own knowledge and then moving forward together. And that's essentially what this is. But to just walk through some of the words because I think they're helpful. Step one is, again, understanding the patient's condition and what they understand. So, what have you heard from your medical team about why you're on antibiotics? Step two is helping a patient explore and compare options. So, the reason I wanna have this conversation is because there are a few different options for your treatment. We can either keep this PICC line in for the remaining two weeks that you have, or if you feel like it's triggering you to use, we can move forward with oral antibiotics. And I want to hear your preferences. The step three is, you know, assessing the patient values and preferences. So, I'd like to hear how those choices might fit in with your life. And then reaching a decision with a patient and validating that, you know, you will support them no matter which treatment they prefer. And so, this, I have a citation here. There's a really nice, in their supplementary materials, they sort of have this conversation guide here that was sort of also highlighted in the past slide. And, you know, I sort of walked through on the prior slide, but I would say like, like I mentioned, step one or sort of setting the scene is often some sort of conversation about asking permission. And particularly when you're in a, you know, anticipating a really tough or sticky conversation, like one in which someone's, you know, been either caught or accused of, say, using in the hospital setting, can be like really, a patient felt really shameful, like they're in a carceral setting, can just be really tough. So, I think getting on their level, asking permission is incredibly important. And then as sort of I previously mentioned, sort of asking their input about, you know, what's their understanding of what's going on. And then sharing your take and exploring their feelings and then sort of moving forward together. I think this is largely along similar lines and you'll have these slides to take a look at if this can be a helpful resource. And what I'll say is, as sort of was outlined in that guide, is that in having this conversation, I think a lot of times these situations escalate between, you know, multiple different members of the care team, like nursing, nurse leadership, sheriff, where things can get very, can sort of feel like they blow up fast and all of a sudden a lot of people are involved that patients like, I'm getting out of here, I can't handle this. And I think that this sort of shared decision-making model that you can again employ in lots of different contexts allows, really like allows you to bring in their perspective. And ultimately in this case, what we assessed is the patient was just feeling really bored in this skilled nursing environment. And having increased cravings, primarily for methamphetamine, which was tough, but also for fentanyl. And so his dose of buprenorphine was increased and the team made a decision to start bupropion for stimulant use disorder. And they made a plan to have daily visits from the addiction care team's patient navigator. He really wanted optimal treatment, felt like I, you know, he understood albavancin as a long acting option or oral antibiotics, but was like, I don't want, I don't want, I want the gold standard. I want what most people are getting. And so wanted to keep that pick. And that is what happened. And they essentially made a plan to say, that sounds good, pending, nothing else goes wrong in this plan for the next couple of weeks. And we don't have any secondary bacteremia or concern that that pick has been colonized and is now its own line infection. We'll keep it in. And that's what happened. So I think that those, you know, four cases overall, like outline this reframing of infectious diseases care for people who use drugs, that's so informed by everything you do in addiction medicine. That's really like bringing in and highlighting shared decision-making, harm reduction in sort of many different clinical scenarios and reinforcing an idea of like, there's no wrong door sort of welcoming the patient wherever they are and trying to move their, advance their care in whatever way we can that promotes health equity. And I think that, you know, we're lucky in addiction medicine to sort of have that be a lot of the norm of our current practice, but I think in ID, and then, I mean, even in, you know, decades past in addiction medicine, a lot of our systems are still like really rooted in paternalism and rigidity and with quite a bit of stigma as well as discrimination for many reasons. We talked about many things today. I will direct you back to this. This article has, I think if helpful to take another look at these cases or you're interested in reading a little bit more, there's some, there's sort of a summary of some of our key points that we hit today here. And if you feel like listening to more, there's a podcast version of this, but I'll stop there and see what questions people have and really thank you for your attention, for using the chat was so phenomenal and I welcome any questions anybody has. You can, I'll go through the chat now and I'm also happy to get emails from people if they come up. Hi, thank you so much for that great lecture. That was really nice to have that case-based presentation to go through all these different teaching points. So far, we've just gotten some thanks in the chat and in the Q and A. If you have any questions for Dr. Appa, please put them in the Q and A. Oh, I see. Okay, I see one from Daryl. Let's see, are you treating with methadone and or buprenorphine along with oxycodone? Oh yes, for case two. Yes, great question. This, so when I was mentioning short-acting opioids in the case of case two, primarily what we're doing in the hospital is starting methadone or buprenorphine for opioid use disorder alongside short-acting opioid agonists with the short-acting sort of being the bridge as we increase the methadone or bup, depending on sort of what speed of start you're going for each of those medications. And, you know, there are some patients that are really not interested in methadone or buprenorphine for, you know, bad prior experiences or what have you. And there, so there, I'd say the minority of patients that are offered short-acting opioid agonists without anything else with really the goal of overdose prevention. I think there's a pretty well-described phenomenon of people sort of losing opioid tolerance when they're in a carceral setting or in the hospital and then having a higher rate of opioid overdose when you leave. And so some people end up sort of deploying the short-acting opioid agonists in that setting too. But yeah. We have one comment in the Q&A here. Getting patients started on a treatment program while in the hospital may benefit the future adherence. Duration being the best predictor of success, it seems like a reasonable place to start. Yeah. Yeah, it's such a great, that's a really great comment. It's so true. I think that they're using the hospital as that reachable moment can both, like you say, allow for sort of new exposure, new starts, like sort of new, the ability to see, say an addiction clinician that that person had not been able to access or thought to access before. So to learn about treatment and also, like you say, just get something started, get that sort of overdose prevention mortality benefit going as soon as possible. So like more days on treatment, more, I think, overdoses averted and lives saved. We do have one question here. How do you manage people who are homeless and leaving the hospital without having completed therapy? What are the considerations? Yeah, really, really great question. That comes up a lot for us. You know, I think that one thing that I always try to do is evaluate why they're leaving. We may not always know, and there are a number of reasons people leave that are not just about say cravings or untreated withdrawal, but if they are about undertreated pain, which we know pain is undertreated in people with substance use disorders hospitalized, or it's opioid withdrawal that we can, that we really like great medications to address. I think like step one is, is there a reversible cause of, you know, why they feel like they need to go? Is there something that we could do to support them better? And then if that answer is no, they need to go for whatever reason, pick up a rent check, take care of their dog, or cravings for methamphetamine, you know, then it's like, okay, how do we work with you to figure out what antibiotic treatment is going to lead to the best shot for success? And so that is where that shared decision-making guide really comes in handy, because you can essentially say share with someone that, okay, so, you know, one option is staying here for another two weeks for your treatment. Another option is a long-acting injectable antibiotic that lasts for two weeks. You'll have to stay here for another hour while we get it ordered and administered. And, you know, it's one of our newer treatments, but we think it's great. And then our third option isn't, you know, oral antibiotics that you have to take, you know, two, twice a day, but it's, you can go now, we can send this to your pharmacy and what have you. And sort of see what they feel like will give them the best chance of success. And then I think that the other sort of practical bit is trying to figure out, you know, we so commonly, because we've all been, you know, in training, we go from inpatient to outpatient, and we really think in like, I'm in clinic, I'm not, but patients are sort of just experiencing the medical system. You know, they're not like, I'm an inpatient, I'm an outpatient. It's sort of just their, it's their life. And so I think as much as we can do to smooth those transitions, like, do you have a phone number? If not, is there a contact person who you are in regular touch with that you'd be comfortable with us putting in the chart? Can we, if you don't have a place to, that you live, is there a place you stay that we can put in the address or put a note in around that? Some of those practical things. Yeah. Okay. Somebody had put in the chat here, I think the name, it's a little cutoff, Janine, said shared decision-making works with SUD patients. Recently completed a study that saw a 7.51% reduction in AMA discharge using it. And then mentioned four drivers for leaving from Simon et al is craving pain, stigma, and hospital roles. Yeah. Those, that, yeah, I think those are really great comments. Yeah, that Simon study is a really important, great qualitative piece of work that sort of delineated those factors. It's worth a read. It's a good one. And, oh, I just saw, I know our time is limited, but I just saw a couple of questions in Q&A. Do you have a way to follow up on people for experiencing homelessness? Yeah. You know, we talked about it a little bit, but one additional thing I'll say is that different centers have different ways of doing either ID or general medicine follow-up for, say, serious infections. And so I think it's always worth talking with your friendly either addiction clinic or clinical team and or ID in figuring out, you know, what pathway is easiest for my patient who's experiencing homelessness to access again? And, you know, is there a way we can allow for drop-in visits? And, or is there a navigator who can support them to actually like get to this appointment that might be hard for them to recall? And, you know, I think that considering what options are lowest barrier for the patient is one thing I think about. And then how often are patients presenting for substance use withdrawal? And I've been, yeah, that's a really also interesting question. You know, at least in our system, you know, there's people are admitted for life-threatening alcohol withdrawal or benzodiazepine withdrawal. They're not as commonly admitted for opioid withdrawal. I think our emergency department is doing a phenomenal job. And I think a lot of local EDs have done a lot better job of managing and treating opioid withdrawal and OUD in the ED setting. Like how can we start you right away? How can we start methadone and connect you? And California Bridge is a really nice example of actually put that in the chat, of a program that's been created to really support, support that effort. And I've just put it in the chat, but it might've just been private. So let me see. Yeah. Let's see. Was there one, one? Okay. I think that was it for all of them. Yeah. Questions. And it's right at six o'clock. So thank you again for such a great presentation and thank you to everybody who has been attending these webinars for the past six weeks. We really appreciate your attendance. Please, to get your CME, go to the AOAAM website, to the education page where you registered for this webinar to get your CME credits. This is our last webinar of the series. So we hope to see you again next spring and please do consider joining the AOAAM if you aren't already a member. And thank you again, Dr. Appa. Thank you all so much. Thank you for the invitation. Take care. Have a good evening.

infections

substance use disorder

HIV care

Dr. Aisha Appa

case studies

shared decision-making

harm reduction

OPAT

antibiotic therapy

multi-disciplinary