Psychiatric considerations in patients with intravenous drug use and endocarditis

Introduction

Opioid use disorder (OUD) with injection drug use has reached epidemic levels with endocarditis as a major potential medical complication increasing the risk of mortality. There has been an increase in the number of hospitalizations, particularly among patients who are younger, white non-Hispanic, and from rural areas [ ]. In one study, among hospitalized patients, 42% were uninsured or had Medicaid coverage, suggesting the high cost and need for prevention and harm reduction strategies [ ]. Treatment for patients with endocarditis secondary to OUD is complex, often involving long hospitalizations, lengthy treatment with intravenous (IV) antibiotics, postacute care at nursing facilities, high rates of readmission, and comorbid mental health illness.

Stigma from both the medical staff and patient can impact the delivery of care and contribute to poor clinical outcomes. One qualitative study enrolled medical staff and patients with both describing stigma leading to delay in treatment as well as fragmented care within institutions [ ]. A systematic review revealed general negative attitudes of health-care professionals toward patients with substance use disorders (SUDs) with perceived violence, low motivation, and manipulation as main themes [ ]. Many patients describe social determinants of health as a barrier to treatment, highlighting the need for a patient-centered approach with integration of treatment across levels of care as well as increase in training in medical staff.

SUDs and psychiatric diagnoses are common co-occurring illnesses. The United States Department of Health has cited 37.2% of patients afflicted with SUDs also have a history of one serious mental illness [ ]. Given the high prevalence of comorbidity, some have argued that dual diagnosis treatment should be the standard of care. For this reason, all guidelines recommend screening for both and a multidisciplinary approach that addresses case management, family interventions, education, self-help groups, pharmacotherapy, and housing. Additionally, treatment strategies of contingency management, relapse prevention, motivational interviewing, and assertive community treatment are recommended [ ]. However, only a small percentage of this population receives this integrated treatment [ ].

In this chapter, we present the common psychiatric illnesses that occur with SUDs with specific considerations for OUD when data are available. Screening, workup, and management for each illness will be reviewed followed by a discussion of clinical approach in special populations.

Depression

Depression is the most common co-occurring psychiatric disorder in patients with SUDs [ ]. Patients with OUDs and depressive symptoms have been found to have lower rates of treatment completion, poorer psychosocial functioning, and higher likelihood of relapse compared to those without depressive symptoms [ ]. The relationship between depression and opioids is complex, bidirectional, and multifactorial.

Epidemiology

Rates of depression in patients with OUD are high across studies and settings. Among patients with OUDs, 27% of treatment-seeking individuals who use opioids meet diagnostic criteria for major depressive disorder (MDD); this number increases to 57% when considering depressive symptoms that do not meet full criteria for MDD [ ]. From 1999 to 2016, there has been more than a 30% increase in overdose deaths [ ], and suicides involving opioids have tripled from 1999 to 2014 from 640 to 1825 [ ]. A study of military veterans with an OUD found that these individuals have the highest rates of suicide (120/100,000 person-years) compared to veterans with other psychiatric conditions [ ]. In another military study drawn from a pain clinic, depression and OUD were found to be additive for suicide risk. Patients with OUD should be screened carefully for current suicidal ideation, recent suicidal behaviors, and history of suicide and self-injury.

Diagnostic criteria and workup

The Diagnostic and Statistical Manual version 5 (DSM-5) defines MDD as a 2-week period with at least five symptoms of depression. These symptoms include: depressed mood; markedly diminished interest or pleasure in activities; significant weight loss when not dieting or weight gain or decrease or increase in appetite; a slowing down of thought and a reduction of physical movement observable by others; fatigue or loss of energy nearly every day; feelings of worthlessness or excessive or inappropriate guilt nearly every day; diminished ability to think or concentrate; recurrent thoughts of death or suicide with at least depressed mood or loss of pleasure being one of symptoms [ ]. Other DSM-5 depressive disorders include disruptive mood dysregulation disorder, persistent depressive disorder (dysthymia), premenstrual dysphoric disorder, substance/medication-induced depressive disorder, unspecific depressive disorder, and depressive disorder due to another medical condition.

Numerous validated tools have been developed for depression screening across settings. The Patient Health Questionnaire (PHQ) is validated for depression screening in patients with SUDs, specifically in patients with injection drug use [ ]. The Center for Epidemiologic Studies Depression Scale (CES-D) and the Beck Depression Inventory are also screening tools that can be used in this population; however, a clinical evaluation is recommended by SAMHSA as a follow-up to any positive screen [ ].

Additionally, medical conditions that cause or present with depression should be considered and include infection (e.g., spinal abscess, pneumonia), cardiac events (e.g., myocardial infarction), nutritional deficiencies (e.g., B12), and endocrine conditions (e.g., hypothyroidism). Hypoactive delirium from an acute medical condition may appear to staff and physicians as depression. Anoxic brain injury from overdose and a major neurocognitive disorder from chronic substance use may also present with apathy or amotivation, mimicking depressive illness. See Table 11.1 for more information.

Table 11.1

Differential diagnosis for depression.

Medical mimics	Infection (e.g., spinal abscess, pneumonia) Cardiac events (e.g., myocardial infarction) Nutritional deficiencies (e.g., B12) Endocrine conditions (e.g., hypothyroidism) Oncological conditions (e.g., pancreatic cancer) Rheumatological conditions (e.g., lupus) Medication induced (e.g., steroids) Neurologic conditions (e.g., multiple sclerosis, frontal tumors or stroke, frontal seizures)
Hypoactive delirium	Numerous etiologies
Anoxic brain injury	Overdose (e.g., opioids) Drug induced (e.g., cocaine-induced vasospasm; progressive leukoencephalopathy from opioid inhalation)
Major neurocognitive disorder	Secondary to chronic substance use (e.g., opioids; alcohol; inhalants; cocaine/methamphetamines)

Treatment

The Four Quadrant Clinical Integration Model developed by the National Council for Community Behavioral Healthcare in conjunction with SAMHSA recommends management of patients with mental health needs across psychiatric, primary care, and other health-care settings. For psychiatric comorbidity, ASAM recommends a comprehensive evaluation to determine stability, direct questioning around suicidal ideation/behaviors to reduce and monitor suicide risk, and pharmacotherapy and other psychosocial interventions as needed [ ].

Selective serotonin reuptake inhibitors (SSRIs) are the first-line recommended pharmacological treatment for patients with depression of all levels of severity. Serotonin–norepinephrine reuptake inhibitors (SNRIs) and other antidepressants (e.g., bupropion, mirtazapine) are also appropriate to use in the first-line management of depressive symptoms in patients with OUDs. While there is good evidence for the use of TCAs in the management of depression, these medications should be avoided in patients with high impulsivity and who are at overdose risk. Choice of antidepressant should rely on the individual profile of the patient, including consideration of drug–drug interactions, personal history of medication use, family history of treatment response, side effect profile, and pharmacokinetic considerations. Appropriate titration of medications should be undertaken with medication trials of at least 4–8 weeks at the maximum tolerated dose [ ].

Psychotherapy can also be considered as monotherapy for patients with mild depression or in conjunction with an antidepressant in patients with moderate to severe depression. Cognitive behavioral therapy (CBT) and acceptance and commitment therapy (ACT) in patients with SUDs have strong evidence to support their use. Use of motivational interviewing techniques can enhance engagement to treatment and facilitate behavioral change. Mindfulness-based interventions have also been found to be effective [ ].

Anxiety disorders

Similar to depressive disorders, anxiety disorders are highly comorbid with OUDs and interfere with coping [ ], achieving, or maintaining abstinence from opioids, and may perpetuate the cycle of addiction [ ]. The lifetime prevalence of an anxiety disorder has been associated with early onset of heroin use and is also a factor associated with rapid transition to addiction [ ]. Moreover, patients experiencing opioid withdrawal or undergoing opioid detoxification may experience significant symptoms of anxiety [ ].

Epidemiology

A review found that 26%–35% of patients with OUDs had a lifetime prevalence of anxiety disorders [ ]. The lifetime comorbidity rates for patients with opioid, sedative, and tranquilizer use with anxiety disorders are cited at 60% (not including PTSD or OCD), higher than with other substances of misuse [ ]. In one study of 90 patients with prescription opioid misuse, panic disorder was the most common comorbid psychiatric disorder (13.9%), followed by generalized anxiety disorder (10.7%) [ ]. Kidorf et al.'s study of over 200 patients with injection drug use found women more likely to have diagnoses of most anxiety disorders [ ].

Diagnostic criteria and workup

The DSM-5 anxiety disorders include separation anxiety disorder, selective mutism, specific phobia, social anxiety disorder, panic disorder, agoraphobia, generalized anxiety disorder, substance/medication-induced anxiety disorder, and anxiety disorder due to another medical condition.

Validated screening tools for anxiety disorders include the generalized anxiety disorder (GAD 7) and the Hamilton Anxiety Rating Scale. The workup for an anxiety disorder in a patient with an OUD includes ruling out medical mimics of anxiety, such as infection, metabolic abnormalities, cardiac conditions (e.g., endocarditis, atrial fibrillation), pulmonary conditions (e.g., pulmonary embolism, asthma), and endocrine disorders (e.g., hypo- or hyperthyroidism).

Treatment

First-line treatment of anxiety disorders in patients with OUDs includes psychotherapy (e.g., CBT, mindfulness-based interventions) and antidepressant medications (e.g., SSRIs and SNRIs). An appropriate trial of an antidepressant is 4–6 weeks at maximum tolerated dose. Patients with anxiety sensitivity may have a lower tolerability of associated side effects, necessitating a slower titration. Adjunctive agents that may be considered in the management of anxiety disorders include buspirone, hydroxyzine, clonidine, propranolol, and less commonly antipsychotics [ ].

While benzodiazepines are commonly prescribed for acute anxiety, these medications are not recommended for chronic treatment, especially in patients with co-occurring SUDs. In a survey of patients seeking opioid withdrawal management, 44% had used benzodiazepines in the previous month; of these patients, 42% used these for anxiety and 27% to enhance euphoria from another substance [ ]. Due to the high potential for misuse, prescribing benzodiazepines to patients with OUDs is discouraged [ ].

Bipolar disorder

Bipolar disorder (BD) is a serious mental illness marked by alternating intervals of elevated and depressed mood [ ]. Affecting approximately 2.6% of the national population, BD is a complex condition characterized by a range of negative outcomes including poor quality of life, reduced overall functioning, increased medical burden, and heightened mortality [ ].

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