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Hi, everyone.
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Welcome to Febrile, a cultured podcast about all things infectious disease.
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We use consult questions to dive into ID clinical reasoning, diagnostics,
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and antimicrobial management.
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I'm Sara Dong, your host and a MedPeds ID doc.
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Welcome to the next Febrile StAR episode.
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These will feature topics and authors from the CID Journal's
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State of the Art Reviews.
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You can listen to episode number 97 for a quick introduction from the
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editors of these reviews, and this is our second of four straight weeks of
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StAR episodes to kick off the series.
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All right, I'll introduce our guest stars today.
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Dr.
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Kinna Thakarar is an associate professor of medicine at Maine Health and
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Tufts University School of Medicine.
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She is an infectious diseases and addiction medicine physician.
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Her clinical and research interests include the ID and substance use syndemic,
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particularly harm reduction, shared decision making, and community based work.
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Hi there.
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This is Kinna Thakarar, and I am super excited to be here today.
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Dr.
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Ayesha Appa is an assistant professor of medicine at the University of California
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San Francisco, UCSF, where she completed ID and addiction fellowships in 2023.
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Her research and clinical priorities are on patient centered models of
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care for simultaneous treatment of addiction and infections including HIV.
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This is Ayesha Appa and similarly, psyched to join this crew.
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Chasity Tuell is a harm reductionist and serves as the Washington County
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Program Director for Maine Access Points.
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Maine Access Points is a harm reduction organization providing syringe access
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services, overdose prevention education, and naloxone distribution, peer support,
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and advocacy throughout rural Maine.
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This is Chasity Tuell.
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Thanks for having me today.
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Thank you guys so much for joining.
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Before we talk about the awesome cases today, we're gonna intro as
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everyone's favorite culture podcast.
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I would love to hear about a little piece of culture, basically something
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non medical that brings you joy.
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Mine is a bit random.
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So I grew up in the Philadelphia area and one thing that makes me
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really happy when I go home is Wawa coffee and a pretzel, a soft pretzel.
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I don't know if, if folks don't know what Wawa is.
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Some may refer to it as like a convenience store, but I like to
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joke that it's really a lifestyle.
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And one fun fact actually is that my parents, their first date was actually
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what is now a Wawa in West Philly.
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And so I think it's just hilariously like symbolic of our, our Wawa.
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That's beautiful.
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I could, I can go, my - I was trying to think about culture apart from the
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noise from my two toddlers that involves like Peppa Pig and things like this.
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Um, mine is not highbrow, but I was just on vacation and was a little late to this
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party but read Fourth Wing, which is this book that is this combination of Harry
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Potter and Hunger Games and also with a sort of like spicy romance element.
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I flew through that.
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So, good escapist rec for anyone.
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Right now one of my favorite joys has like really been junior high sports,
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which sounds so weird, but we're so invested in it at the moment, and
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being able to see how much the kids are changing and gaining confidence
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throughout the year has been so fun.
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And I've, realized I've turned into one of those people who just
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like randomly is looking at kids smiling so proud of them and then
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realizing like, I look like a freak.
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That's definitely it right now.
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Oh, I love it.
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Oh, thank you guys for sharing those.
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You know, I'm really excited to have you here.
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We're going to chat about your state of the art review, uh, which is entitled
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Frame Shift, Focusing on Harm Reduction and Shared Decision Making with People Who
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Use Drugs Hospitalized with Infections.
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I thought I would actually just ask if we could start with giving an introduction,
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the things that you were thinking about as you were crafting this article.
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Well, first I should give a shout out to the editorial team at CID
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for actually inviting us to do this state of the art review.
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You know, it was really meant to not just cover
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clinical presentation and management for people who use drugs, but
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they really wanted us to have like an intentional focus on shared
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decision making and harm reduction and approaches to reducing health
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inequities for people who use drugs.
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So, you know, with that, we, we consciously developed
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a multidisciplinary team.
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So, obviously, there's Chastity and Ayesha here today, but we also,
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our team included a PharmD, Jacinda Abdul-Mutakabbir, an addiction medicine
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nurse practitioner, Amelia Goff, and LCSW, Jess Brown, and then also actually
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my own mentor, Kathleen Fairfield, who's an expert in shared decision
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making, and of course, our amazing ID scientist colleague, Alysse Wurcel.
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What we did is we created some clinical cases to really illustrate a spectrum
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of fairly common scenarios, I think, and we provided viewpoints, especially
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where we don't have robust data.
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So, in the review, we tried to offer strategies for ID clinicians to use that
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really incorporates tenets of shared decision making and harm reduction.
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Before we dive into the cases, too, it's probably helpful to understand some of the
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barriers that people who use drugs face.
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So, I'm hoping, Chasity, maybe if you wanted to weigh in on this and just
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given your experiences in the field.
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Of course, so I am in very rural Maine and there's so much context in that.
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The landscape of the way the state is, so much is rural and we have to travel
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so far for anything and everything, not even just the length of travel.
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There's very limited, if any, public transportation.
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My area, we don't even have a taxi.
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There's a lot to think of there, so it makes it really challenging
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to get folks to appointments and anywhere they need to be.
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With that too, there's like a lot of the small town stigma that people face.
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I know that I have a lot of participants I encounter that won't go to the emergency
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room or won't go to local providers because someone they know that works
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there, or a family friend, or they had a rough couple of years in life,
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now they're excelling, but they're By their past in this really harmful way,
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a lot of times I think in policies and just decision making in general,
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those pieces don't get thought about.
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And it is such a huge piece of if people will choose or not choose to
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get the care that they really need.
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That's such good perspective.
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I think from like contextually, as I'm rooted in San Francisco
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on the other side of the country in a very urban environment.
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I don't often think about that with a small town perspective, though people
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who use drugs and are folks that we're interested in talking about today, what
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I hear is similar fear of discrimination.
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In that folks are using the same county hospitals or same couple of safety net
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institutions, and whether it's stigma and discrimination, really, that they've
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faced related to using drugs, or whether it's race, ethnicity, sexual orientation,
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sex or gender, approaching or, or really circumventing that takes a lot of courage
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on the part of people who use drugs when they've faced that in the past.
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And so that is, is one barrier is like even getting in the door and then in the
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line of sort of inequity and diagnosis and prevention and management of both
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infections and substance use disorders.
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It really like runs the gamut of, Implicit bias in prescribing antimicrobials
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or structurally racist policies that have sort of segregated our
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medications for opioid use disorder.
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There's just a lot of intersectionality really in creating these
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overlapping systems that can make it tough to get really good care.
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Also, maybe before we kick off with the cases, I'm sure most people know
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what harm reduction and shared decision making are, but maybe it would be
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helpful just to give a brief overview.
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Chasity, would you want to go over the definition of harm reduction.
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So harm reduction by definition, and you will see this in all policies now,
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is a set of practical strategies and ideas aimed at reducing the negative
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consequences associated with drug use.
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It was also built on a social justice movement for and by people who use drugs.
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In practice, that is autonomy, letting people have the right and
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the choice to what is best for them.
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Yeah, thanks for that.
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And I think, you know, from a clinical perspective, too, Ayesha,
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feel free to weigh in, but, you know, I think a harm reduction based
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approach to treating people who use drugs is really just so important.
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Just like what you said, you know, patient autonomy and making sure
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they're included in treatment plans.
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You know, that's where I think shared decision making comes in too.
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It's really a collaborative process where really, you know, the patients and their
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values are at the center of the decision.
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And so, I think we're just seeing more and more of that in treatment guidelines
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and especially where there's evidence that's still emerging or ambiguous.
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Harm reduction and, and shared decision making can be really
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helpful when we're caring for people.
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My simplistic take on it is that harm reduction is radical love.
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Like you're just like really trying to like see that person where they are and
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say like, I appreciate you for coming at whatever phase of change or not change.
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You are, you are just a human in front of me that I will
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help be as healthy as possible.
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All right.
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Are you guys ready to jump in with our example scenarios?
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Yeah, let's do it.
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Awesome.
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And all of these, I have to say as the reader of the paper that you've
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created, all of them feel familiar.
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I feel like all of these examples were things that I have participated
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in or, or been a part of.
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So our first scenario is we meet a 35 year old woman who is hospitalized
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for one week of fevers and rigors.
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She had taken a couple of days of doxycycline that she had received
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from a friend prior to coming in.
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On admission, her blood cultures from the ED demonstrate Streptococcus
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mitis, and then further workup identifies a dental infection.
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Ultimately, she has three days of bacteremia.
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Her co occurring conditions include anxiety, opioid use disorder,
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and a history of IV drug use.
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Her current treatment includes methadone and attending recovery group.
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She has no recent drug use or cravings.
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For a little bit more clinical info, the TTE and TEE were negative for vegetation.
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There's been no signs or symptoms of infective endocarditis.
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She successfully undergoes a dental extraction and during the admission, her
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home dose of methadone is continued and she attends her recovery group meetings
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virtually during the hospitalization.
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So now it's four days or so later, and she expresses to you
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her desire to be discharged home.
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She wants to be home with her children and complete the rest of the course
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with IV antibiotics because I didn't mention this, but she had been unable
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to tolerate some of the oral antibiotics that were tried during her admission.
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You know, she tells you, I feel like I can safely care for my PICC line at home.
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She's eligible for home health services and, and shares that she understands
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the risks of incomplete treatment and has really good family support.
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So how would you guys approach this scenario?
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Let's see.
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Well, Chasity, would you want to weigh in maybe a little bit before we dive
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into the management and maybe just thinking about potential barriers
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she may have faced in coming to the hospital that could have impacted her
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care, or things we could do better.
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Well, as it was asked, who wants to take this?
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I was thinking, I'm not a doctor, these questions aren't for me.
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But I can see myself on the other side of it, like as the patient,
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Yes.
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So important.
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There's so many pieces like, and I think as a mother also that is
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relevant, like we put off our own care to take care of our family.
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So that's adding just another level of barrier to this.
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So it's difficult to try and go take care of yourself,
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especially if you have children.
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And if there's been any negative experiences, and I think at some point,
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everybody has had a negative health care experience, even very minor, all
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of that weighs on us being on methadone, that's already so high barrier for
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people in any ways, because there's so much asked of them to go daily, multiple
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times a week, whatever it is, it's so restrictive and it takes so much time
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and takes away from our family, our jobs, and all of our responsibilities,
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it is really difficult to get yourself to the point to go to the hospital
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and have to spend so much time there.
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Other people that haven't lived through any of this think
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that just sounds ridiculous.
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Like.
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Well, you have to take care of yourself.
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And it's like, yeah, we do, but there's also all of these other
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pieces people aren't thinking about.
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I know it's very easy to dole out the advice and then think about like, oh, yes,
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how am I getting to my own appointment?
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I can barely hold this together.
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Like, how are we expecting this person with dependence and a daily need
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to go to a clinic to do all this?
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Getting back to your question, Sara, of like, of how do you manage this scenario?
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Or how do you approach this??
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If there's one thing that you remember from this case, I'd want it to be that
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substance use is not a contraindication to discharging people home with OPAT.
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It's really easy for us to look at the chart and say like history of IDU
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and have that color this person's care going forward in perpetuity, but being
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a part of this article was a really nice opportunity to dive into this
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grey area and really help people work with their patients to make a decision
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about the best treatment strategies.
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In this case, this person is someone with opioid use disorder in remission
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who's on methadone, who hasn't described recent injection drug use.
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And so it is someone in whom I'm not so worried about the risks of,
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say, secondary bacteremia related to injecting through a PICC.
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I am really not worried about life chaos that might be associated with some people
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who are using and, say, experiencing homelessness or using stimulants, etc.
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This is somebody who's housed with kids.
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She's getting a lot of stuff done for her.
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And so, broadly, consider OPAT for people using substances, and then be specific
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about what, what the concern might be if there is one related to substance use.
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We go into some of these data in our article.
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Joji Suzuki and colleagues from Partners did a really nice review published
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in OFID looking at essentially the data quantifying adverse events or
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successful completion of OPAT in people injecting drugs or using drugs.
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And so I'd refer to that in our section of that article if you're
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feeling the need to be bolstered.
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The other thing too I sometimes bring up with folks if you do get pushback
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is like if they're being denied OPAT.
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I mean, that It could be considered, you know, a violation of the Americans
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with Disabilities Act or the ADA, and so, I mean, I'm not a lawyer,
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obviously, but what is recommended is you, there are ways to, you know,
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file a report, and we just, like, have to advocate in situations like this.
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So, but I totally agree with everything that s been said.
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One other thing in terms of management is, you know, how to incorporate
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shared decision making for this case.
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You know, I think we know, we all know that these prolonged hospitalizations
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can be really harmful for patients and some clinicians, though, may perceive
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that being in the hospital, you know, it's a protective environment, but the
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reality is, you know, people they want to use drugs are going to use it, you
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know, even if it's in the hospital and like Chasity said, they, you know, folks
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have families or job responsibilities.
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And so they may not want to be there for that long.
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And so they can also, you know, have stigmatizing encounters
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or get nosocomial infections.
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So I think it's really on us to really, you know, meet with each patient and
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everyone's going to have different values and preferences and goals and really try
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to incorporate shared decision making.
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You know, one thing I've heard from colleagues.
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I was like, oh, it's it's so time consuming.
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And so, you know, we have borrowed from the palliative care field where they
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use the serious illness conversation guide, which is really considered
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best practices in palliative care.
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And so there's not much data in people who use drugs.
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So in Maine, we actually ended up building on shared decision making
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and this conversation guide to develop and implement a guide that
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was specific to people who use drugs.
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And I mean, it was pretty well received.
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It was a small pilot study.
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Obviously we need more data and more research, but it was really promising
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and it was a way to really incorporate patient preferences, discussing treatment
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options and tradeoffs for different approaches, and then just, you know,
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closing the conversation, documenting it, and communicating with physicians.
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So in this particular case, though, you know, we recommended in the review
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to have this, you know, structured conversation, understanding this patient's
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preferences, and you know, she has a good understanding of her infection and
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the different treatment options, also has stable housing, family support.
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So, we recommended that the primary team consider discharging her home with OPAT,
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you know, the methadone environment is pretty restrictive in terms of
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the regulatory environment right now.
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And so, if this patient has to go to the methadone clinic every day,
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you know, considering something like ceftriaxone once a day, just so that
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doesn't interfere with her going to and from the methadone clinic.
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Totally.
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I was going to say the exact same thing as like that concrete pearl for ID providers.
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It's like know your patient's lives.
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And again, this applies to everything, not just people who use, but, but, you
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know, know their lives and what fits in.
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I think OPAT providers are really good at trying to select antibiotics that
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will be least burdensome, and that's like particularly true, I think, with
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thinking about how methadone fits in.
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Excellent.
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Okay.
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So we're going to go on to our next scenario.
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This time we meet a 44 year old male who injects fentanyl and is
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experiencing homelessness after recently being released from jail.
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He's currently hospitalized with MRSA mitral valve endocarditis.
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So there's a 0.
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5 centimeter mitral valve vegetation noted on TEE with no other abnormalities.
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So the multidisciplinary endocarditis team recommends medical management.
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The inpatient addiction consult service diagnosed him with opioid use disorder
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and the patient identifies his goal as abstaining from further fentanyl use.
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In hospital, they initiate methadone with a plan to up titrate while he is there.
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He meets with a licensed clinical social worker to help
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facilitate housing applications.
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And after about four weeks in the hospital, the patient feels that
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he is at a stable methadone dose.
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He is not experiencing significant cravings.
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And though he has not yet secured housing, he starts to express
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his desire to leave the hospital.
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He does not want to be discharged with a PICC, but does want his infection
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to be treated the best that it can.
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And the other additional piece of information is that he does have a sulfa
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allergy with a history of anaphylaxis and his medication list includes sertraline.
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What do you guys think?
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How should we approach this case?
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Thanks, Sara.
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I am, in thinking about this case again, just feeling really thankful that we
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are where we are today, even if we have a long way to go, and like, really
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delivering equitable care to people who use drugs, you know, in this case, we are
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taking care of somebody who is admitted to a hospital with an addiction consult
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service, which may not be the standard for every hospital in the country.
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And again, this is specific, but this is a very different clinical stem than, let's
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say, I think patients that I was seeing in residency not so, so long ago in 2015.
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There's this implicit understanding in the stem you presented that treating
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addiction should be standard of care when managing infectious complications of drug
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use, or when really just like seeing a patient with a substance use disorder at
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a touch point that is the hospitalization, thinking about, you know, what can we do
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in a wraparound way to treat this person's addition, how can we advance their care
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and really treat the root cause of this infection and prevent further infections
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is the standard, which is fantastic.
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Generally, he's gotten a diagnosis of opioid use disorder, gotten
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started on methadone, which is fantastic and is getting uptitrated.
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When I see that he's at a stable methadone dose after four weeks in
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the hospital, that's another huge win.
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This is somebody who stayed in the hospital or, you know, in a supervised
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setting for a month whose dose was up titrated effectively, which is often,
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you know, we're often seeing folks leave potentially in the setting of meds for
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opioid use disorder not even being started or offered, or doses not being adequate
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enough to address either withdrawal or cravings and really get to a stable dose.
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Those are wins in the stem and things that I encourage anybody listening
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to, to make sure are in place in your medical settings that you have
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a way of offering buprenorphine and methadone for opioid use disorder and
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thinking carefully about what your, what your resources are for stimulant
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use disorder and all use disorders that may be related to someone's infection.
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The last thing I'll just say about that broadly is I know that the access
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to methadone is really fragmented and different across the country.
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And so there may be, I think there are opportunities for advocacy on the
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individual systems level, or like medical, medical center level, you know, up
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through state and federal levels here.
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Kinna, maybe I'll ask you your approach to, we have some specific
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information about where he is in his course of endocarditis treatment,
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and I'm curious how you approach the antibiotic prescribing options.
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This also gets back to the, you know, conversation guide and making sure that
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we offer any quote unquote non traditional options, so that could include long acting
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antibiotic infusions and oral antibiotics.
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So, you know, for this case, he's made it, you know, pretty clear he doesn't
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want to PICC but we could discuss dalbavancin or oral antibiotics.
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In the interest of time, I'm not going to go through all of the options,
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but you can read in the review.
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But also, you know, I think it was Dr.
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Baddour and actually Dr.
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Wurcel as well.
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They have a really great paper and It was published in Circulation, I believe, in
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2022 that really summarizes very well, sort of, going through the feasibility
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of these different options for people who use drugs with endocarditis.
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So, I definitely recommend reading that.
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But I think just generally, you know, thinking about each option, you know, for
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this patient, do they have transportation to get to a center where he can get a
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long acting injectable like dalbavancin?
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Obviously, you know, there's still RCTs going on to look at dalbavancin
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in infective endocarditis, but there's really promising data.
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Also talking about oral antimicrobials in this case would be relevant and
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we should definitely do that for this patient just knowing his goals.
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At the end of the day, thinking about structural drivers of health
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and the feasibility of treatment options should be prioritized.
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And I think the other big discussion point that we had in the paper is
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also making sure that we prioritize treatment for substance use, looking
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at any drug drug interactions, because we know that there are certain touch
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points where people are at very high risk for overdose, and sadly, discharge
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from the hospital is one of them.
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And so, if patients want to go on treatment, I think we need to
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do our best to, like, make that transition as smooth as possible.
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So, just as like a concrete example here for this case, thinking about the
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POET trial, for example, they looked at linezolid and rifampin, but we
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know that rifampin can markedly reduce methadone levels and may, you know,
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reduce buprenorphine levels, and so would we want to perhaps consider rifabutin
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instead of rifampin or just, you know, go with linezolid monotherapy knowing that
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there may be, you know, limited data.
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So I think it's just talking about these tradeoffs and options openly
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with patients is best practice, but And it's probably obvious, but I think
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it's important to also say that we should, we recommend, again, stopping
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substance use treatment like methadone and buprenorphine just to accommodate,
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you know, antimicrobial options.
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The other unique thing about this case is him being in a rural state, right?
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So I think we know that rural areas are really disproportionately burdened
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by substance use and drug overdose deaths, and people have limited
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access to certain types of care.
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So, I don't know, Chasity, if you want to weigh in here a little bit for this
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case too, because since you work in one of the most rural counties in the U.
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S.
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Yeah, I was looking at it and thinking about the fact that they
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still haven't secured housing and they're in rural Maine.
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There's so many layers to that.
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They're going to need to get to their clinic, and since they're a new patient,
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they're going to have to go often.
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But they also don't know where they're sleeping, so adding any
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restrictions on treatment is going to make everything in their life harder.
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We have to travel really far, and we don't have shelters, so we do
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a lot of couch surfing, and we don't even have, um, encampments
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like you have in bigger cities.
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So, as terrible as that is, there's no sense of community for the people
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experiencing homelessness in rural Maine.
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So, it's really isolating.
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So, I think in cases like this, just being able to connect folks to people
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that are already embedded in the community is really, really important.
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And then they have another touch point for anything that they need.
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We're, we're small town Maine.
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If we don't have an answer, we know who has the answer.
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I love that.
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One other thing that I'll just add around the drug drug interaction point.
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I agree.
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I hope most people aren't in a cavalier fashion stopping methadone
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or bupe, but I've had many a good conversation with folks about
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like, you know, the rifampin is
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important.
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And that's what's evidence based.
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Our data for rifabutin are poor or our data for monotherapy or some of these
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alternative options are not there.
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And, and so like, can't we just increase the methadone?
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Of course there are many options on the table, but disrupting someone's
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stable methadone dose with PK that's like really unreliable, like that
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you cannot really predict when, if any, and to what degree someone's
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effect will, will be felt from that.
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Induction via rifampin is incredibly destabilizing.
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I've seen a number of patients who've been on RIF and didn't really
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understand what was going to happen and returned to use and again,
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really destabilizing in their lives.
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So would really prioritize maintaining that methadone whether it's drug drug
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interaction wise, or just the act of, of, of going, um, and, and having a
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conversation with your patients, with your addiction medicine colleagues, if,
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if there's questions to, to get at that.
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Great.
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All right.
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And I'll move us forward to our next scenario.
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This time we meet a 35 year old transgender woman who is
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experiencing homelessness.
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She is admitted with pan susceptible Serratia bacteremia in the setting of
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IV fentanyl and methamphetamine use.
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She has been injecting drugs with non sterile water, shares needles, given there
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is no access to a syringe service program in her primarily Black neighborhood.
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The patient occasionally engages in primary care through
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a local mobile health unit.
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She is not currently interested in outpatient substance
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use disorder treatment.
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Her bacteremia is initially treated with cefepime, and opioid withdrawal
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is treated with short acting opioids.
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Two days into her hospitalization, She decides to leave the hospital.
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It's midnight and you get a call to ask for help on, on how to move forward.
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So I will say that the, you know, goal of having structured conversations
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about treatment options and their trade offs is to hopefully minimize
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unplanned discharges like this and, you know, talking about oral antibiotic
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options and, um, documenting them and putting it in the chart so that cross
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covering teams can use that information if an unplanned discharge happens,
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you know, that's the ideal situation.
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But that being said, you know, unplanned discharges can happen and oftentimes
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it feels like it's always at midnight or overnight and there is a really
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great, it was a single site study, I think by Laura Marks and colleagues,
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where they showed that at least offering oral antibiotics compared to
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no antibiotics had better outcomes.
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So, I think at the end of the day, the take home point here is like, there's
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always something we can do for patients on discharge, whether that's, you know,
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oral antibiotics, naloxone, or, you know, something I always talk about
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with trainees is just contact us and we can still get, you know, expedited
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telehealth or follow up ID visits.
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In Maine, we work very closely with our homeless health partners.
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So, we'll just message them afterwards to try to arrange follow up and in
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Laura Marks' study, they looked at how those follow up visits were really
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helpful for discussing PEP or PrEP and harm reduction counseling, making sure
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they actually got their antibiotics if they were discharged or, you know,
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whatever other help they needed.
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Just recognizing that, especially for this case, there are still things that
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we can do to really, you know, optimize this patient's health and safety.
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So, the hospital really can be an opportunity for, infectious
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disease screening and prevention.
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So when this patient is hospitalized, it'd be great to go through, like,
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how does, how is she using drugs?
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Um, does she have access to syringe services programs, naloxone, and
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talking about screening for STIs, PEP and PrEP, all the things, and,
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you know, seeing if she has access to local harm reduction organizations.
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And the other part of this, I think, too, is making sure folks, you know, offering
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screening for HIV, other STIs, including extragenital testing, CDC really says,
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you know, annual testing, but I think in this review we said at least every
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three months or even more frequently depending on how people are using,
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right, if they're sharing equipment.
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Maybe they need, you know, more frequent screening.
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Also, for this patient early on, we tried to offer her vaccines.
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Here in Maine, actually, we're seeing, we have some of the highest
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rates of acute Hep B and are having clusters of Hep A infections now.
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So, offering, you know, Hep A and B vaccines, Tdap, Prevnar, COVID, all
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the things and, you know, we know that even 1 dose of hepatitis vaccine
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can provide some coverage and you don't have to wait for serologies.
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That's per CDC guidelines and so trying to offer all of these things as
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early on as possible so that if they do leave early, you know, there are
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some preventive strategies in place.
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I think this can be like a lot, somewhat overwhelming to think about.
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So I think like, if you have a way to do this systematically,
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wherever you practice, it's helpful.
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You know, like in Maine, we have a little checklist in EPIC.
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We have a smart phrase that we use and, you know, folks have done some studies
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on bundled interventions and toolkits and it is feasible, I think, to, to do this.
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Yeah.
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I really just want to underscore how validating, or I think like
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offering those, I was going to say harm reduction screenings, but it's
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really just general health screenings.
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And again, that sort of no wrong door opportunity to offer screening and
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testing for things that, you know, you may have done in a clinic setting, but
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again, like someone's here accessing services, like how can we offer it?
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It can be just a beautiful start to a conversation with someone that feels
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It's very validating, like, ah, yes, you're not going to push treatment
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on me because that's not what I'm interested in, but you're going to try
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to optimize my health and know that I care about my health regardless.
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It's really easy when we've gone through medical training that's like heavily
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inpatient and you're doing these like blocks of time in the hospital and
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then maybe you have like little smidges in between of clinic, like you really
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think about life as like the hospital and then the clinic, but patients are
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not experiencing life that way, right?
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Like they're, they're going in and out and this, like this is their life and
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their health and they're contending with doctors in different places, but
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it's really the infection or the XYZ cause of hospitalization, not the care
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setting that they're orienting around.
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And so it's really artificial that we orient ourselves that way.
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If we want good outcomes in, in people who use drugs, like we have to understand,
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like, where might they be going afterwards or are used to going or, or how can
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we work with, whether it's community based organizations, syringe access
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programs, or just models of care in clinic, you know, in our institution,
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we have our, our HIV clinic, Ward 86, has a drop in model serving people
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experiencing homelessness called pop up.
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You can come in anytime.
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There are no appointments as, as there are similar sites sort of around the
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city, and I know around the country, if you are that person in the hospital
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thinking about, what are my resources?
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Like, who can I figure out that I can contact for this patient, to help them
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land more seamlessly, that would be one thing, and the other, I would say,
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is when thinking about that person leaving at midnight, as again, as
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Kinna said, like, we're going to try to figure out an oral antibiotic plan
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or some antibiotics better than none.
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The other thing that I don't think is too much to ask is, like, thinking
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about what harm reduction interventions you can offer, whether it's
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naloxone at bedside or at discharge.
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Our hospital recently started doing, like, providing safe
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consumption supplies at discharge.
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Leah Fraimow-Wong and team published this recently, JAMA Network Open, that's
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looking at, you know, how much patients and other stakeholders valued that.
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I'm really glad to hear you guys are giving out supplies
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to people at discharge.
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That was one of the things that really stood out to me in this.
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Like, why can't people just get what they need when they leave?
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It, it's medical supplies, so they should be able to get it.
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And the fact that this patient meets with a mobile health unit, that seems
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like such a missed opportunity to not have a syringe service program
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embedded there, or partnered there, anything low barrier is It's always
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going to be the best way to get people.
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People need community.
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Having low barrier services in the community instead of in
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the hospital setting is always going to be what folks need.
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Thanks Chasity.
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Well, I will round us out with our last scenario here.
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Um, this time we meet a 25 year old man.
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He is experiencing homelessness with chronic hepatitis C virus, opioid
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and stimulant disorders, and recent MSSA prosthetic valve endocarditis.
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He is receiving IV cefazolin through a PICC line at a local
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medical respite care center.
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Through the care center, which serves people experiencing housing
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insecurity, he can receive this continuous care, so IV antibiotics,
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following his hospital discharge.
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So, his additional treatment includes methadone for opioid use disorder
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and mirtazapine for stimulant use disorder, as well as counseling.
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Four weeks into treatment, he's still unable to secure housing and discovers
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that he has lost his job permanently.
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The respite care staff are alerted that a nurse found a syringe in his bed.
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There is concern that he had used his PICC to inject
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methamphetamine over the weekend.
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Otherwise, he is hemodynamically stable, doing well, and just prior
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to his scheduled ID follow up appointment that week, the respite
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care staff call and ask how they should proceed with his treatment.
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This is a tough scenario.
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Again, as in the other case, there are many things I think that this
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is going well here and that this is someone who is receiving shelter and
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is four weeks into his antibiotics on methadone and sort of interested in
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help for reducing his stimulant use.
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The approach that I take to learn more about ongoing substance use
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on addiction treatment and on infection treatment that may involve the PICC is
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first starting by setting the scene well, making sure that you have the time and
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space to have a conversation that's, you know, 15, 20 minutes longer, sit down,
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look your patient in the eye, hopefully you have developed a relationship,
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and then ask permission to have a conversation about ongoing substance use.
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And that may look like, hey, do you have a minute, a few minutes, like that.
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Can we talk a little bit about drug use.
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That scenario of Oh, I, you know, heard XYZ thing from someone in the
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care team that this person is using happens a lot or this comes up a lot
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and can often feel like telephone and knowing what truth is, is hard.
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And so I would start by sharing frankly what you've learned and then
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asking for their story or asking their understanding of sort of what's been
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going on or how things have been going.
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And then I really have loved Kina's article about shared decision making
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that references and I think brings up training that we've had around
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like ask, tell, ask and and really eliciting the patient perspective and
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continuously getting a sense of where they are when having this conversation.
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While this may feel disheartening, again, there are many successes that
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are happening here and that you can sort of approach this conversation
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and have one that is still warm, welcoming, and open one with, with
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your patient when trying to negotiate, okay, what, what's best moving forward.
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I think it's really important for people to hear and not expect that
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just because someone's in the hospital receiving treatment or on, you know,
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any sort of maintenance medication.
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That doesn't mean they're going to stop drug use.
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There's so many factors that go into that, and it's not black and white,
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so to expect that everything's just abstinence because someone's being treated
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for something is really concerning.
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I feel like this would be an opportunity to really say like, you know, This is
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why we need a safe supply like across the board for all medications and it would
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be a great time to advocate for that.
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I like what you said about having the conversations with the patient and asking.
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If you don't have a great relationship already built up, people aren't going
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to tell you anything because for so long, you know, this is drug use
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is just criminalized and shameful.
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So we have to lie and hide and hope that people are believing us when we
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know they probably aren't believing us, but we're not going to tell you
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the truth because it's shameful.
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Really being conscious about how you talk to people, that, that is great
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and I'm glad to see such a shift.
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Yeah, I totally agree with what both of you have said, and I will say this is
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actually based on, loosely based on a real case that we saw, and, you know,
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I think we did exactly that and, you know, we invited the patients for visits,
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asked permission to talk about things and, you know, describe any triggers you
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may have had, and, um, In reality, in terms of, like, the clinical management,
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if helpful, you know, we did check, you know, 2 sets of blood cultures,
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CBC with diff, CMP, CRP CRPn, and, um, what we did is really just, you know,
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document the structured conversation, trying to, you know, again, talk about
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the different antibiotic options.
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The patients still want the PICC, do they want to do long acting
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instead, or oral antibiotics, and, you know, just making sure that he
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had, access to safer use equipments.
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And also the other thing we did was reaching out to make sure that the
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respite care center had naloxone on site.
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Everyone was trained in overdose reversal, which they were, which is great.
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So, you know, for this particular case, we, you know, wouldn't, wouldn't recommend
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for him to go to the hospital or pull the PICC line, because, you know, it ended
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up being his preference that to keep the PICC in and, you know, he under, we kind
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of went through safer use practices.
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We know that he has hepatitis C.
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So, I think it's just probably important to flag that substance use is also not
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a contraindication to hep C treatment.
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So we do want to end the hep C epidemic.
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I think it's really important that we treat people who use drugs and it's
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probably worth noting too, that there's a bunch of places, Madeline McCurry and
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colleagues wrote a nice paper on this, but there's a lot of places that have created
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processes for, you know, discharging people who use drugs with prescriptions
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for hep C treatment, or at least starting the process for hep C treatment
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in the hospital or just afterwards.
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I'm just encouraging ongoing screening as needed afterwards in case of reinfection,
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which honestly the rates of reinfection thus far is, you know, fairly low,
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so just a plug for hep C treatment.
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I'm so glad you brought that up.
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It's true.
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I think there was just some, there's an article in the Lancet, I forget
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which one, that is essentially like, we're not doing, we're not doing
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so great with hep C elimination.
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I agree.
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I love the work that people have been doing, innovating to, to, hep C treatment
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earlier, but this case is a good example.
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Like he's four weeks into treatment, could have been four weeks into hep C treatment.
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Exactly.
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Well, I am so so grateful that you guys joined Febrile and, you know,
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helped us think about how to take care of the example scenarios here.
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I just want to leave the ending here for asking if you have any additional
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either take home points or highlights that you want to make sure we talk
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about before we finish up the episode.
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I just really want to say that I appreciate that harm reduction is being
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recognized on a much larger scale.
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I also need to acknowledge that it's not being recognized in
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appropriate ways across the board.
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It's really important to continue having conversations and letting
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people know, like, people who use drugs, they're just people.
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Like, the who use drugs part doesn't matter.
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We're all just people.
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We are no different than anybody else.
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Yeah, that's it.
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A take home point from my angle is that these cases, which we see all
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the time, right, are so common, all included areas in which there's a lot
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of uncertainty in the medical literature around, you know, How best to choose
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the right set of oral antibiotics, or oral versus injectable, et cetera.
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How best to couple infection treatment with substance use disorder
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treatment, or infection treatment with harm reduction interventions.
Speaker:
So we need a ton of more data, and we also need a ton of work that
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centers the patient voice in all of this, like what do patients want?
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What works for them?
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Again, sort of traversing the inpatient outpatient spectrum and, and providing
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really good models of care that are, that are truly patient centered.
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And similarly to support that, whether it's grant mechanisms or IDSA and CROI,
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shout out to those to, to, you know, add, continue to think about focusing
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on this area will be really helpful.
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And we've talked a lot about barriers.
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I think on a hopeful note, I'm really grateful that to work with people who
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use drugs or folks that have not been in the lines of antibiotic treatment
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or, or like what we normally do, because I think it is a nice opportunity
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to push us outside of like, what are our evidence based treatments?
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Like, what are they based on?
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And how can we think outside the box and have better fit into people's lives?
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Yeah.
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At the end of the day, I think when caring for people, drawing on
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principles of shared decision making and harm reduction can just really
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help to optimize patient autonomy.
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Like you said, Ayesha, just making sure that we include patient voices
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and really optimize health and safety, which is at the end of the day what
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we want for all of our patients.
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Last, I just want to add one piece.
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I think in talking about harm reduction and especially in medical settings that
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it's a great opportunity for everybody to really be advocating across the board
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for access to a safe supply, overdose prevention centers, need based syringe
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service programs, and change all the policies like We could be leading the
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way instead of having to be reactionary.
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I'd love to also just put in a plug for IDSA's member advocacy program, or MAP.
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You can go on the website and sign up and get involved with a
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lot of these policy changes, too.
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Thanks again to our guest stars, Kinna, Ayesha, Chasity for joining Febrile today.
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You can find their article, Frame Shift, Focusing on harm reduction and
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shared decision making for people who use drugs, hospitalized with infections
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linked in the episode information and on the Consult Notes.
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Don't forget to check out the website, febrilepodcast.
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com, where you can find our Consult Notes, the library of ID infographics,
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and a link to our merch store.
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Febrile is produced with support from the Infectious Diseases
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Society of America, IDSA.
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Editing and mixing is provided by Bentley Brown.
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Please reach out if you have any suggestions for future shows or want
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to be more involved with Febrile.
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Thanks for listening, stay safe, and I'll see you next time.