Bacterial Infections From Opioid Abuse May Also Increase Stroke Risk

People who misuse opioids and other intravenous drugs are at increased risk for endocarditis, bacterial infections of the heart, which can compound the stroke risk associated with drug abuse, a new study suggests.

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Endocarditis is a complication of opioid abuse and IV drug use.Adobe Stock

Rare bacterial infections of the heart are surging among people who abuse opioids and other intravenous drugs, a trend that may also be leading to more strokes in this population, according to preliminary results from a study presented in March at the American Stroke Association’s International Stroke Conference.

The study focused on 351 patients treated for endocarditis, or bacterial infections of the heart, at Ohio State University’s Wexner Medical Center from January 1, 2014, through July 1, 2018. During the study period, the proportion of patients who had endocarditis caused by intravenous (IV) drug abuse climbed by 630 percent.

Overall, 170 patients in the study, or 48 percent, had endocarditis due to IV drug abuse. Among this group, 26 percent of patients had a stroke, almost twice the rate of stroke among patients who had endocarditis due to other causes.

In addition, people who had endocarditis from drug use were more than 5 times more likely to be homeless, more than 3 times more likely to be uninsured, and more than twice as likely to be unemployed.

“Our research suggests that the impact of the opioid epidemic is far-reaching and contributes to increased costs in the criminal justice, healthcare systems, and the workplace,” says study coauthor Shahid Nimjee, MD, PhD, an associate professor of neurosurgery and surgical director of the Comprehensive Stroke Center at the Ohio State University Wexner Medical Center in Columbus.

“The increased costs can be particularly substantial for stroke care,” Dr. Nimjee adds.

Patients with endocarditis caused by IV drug use had more than double the medical costs of patients with endocarditis from other causes, Nimjee says. This amounted to roughly $100,000 in extra medical costs for each hospital stay for endocarditis that was due to IV drug use, Nimjee says.

The study results are preliminary, and haven’t been published in a peer-reviewed medical journal or independently verified. Other limitations of the analysis include the lack of data on other risk factors for stroke as well as the potential that outcomes from one hospital don’t reflect what would happen elsewhere.

Earlier Studies Link Opioids to Endocarditis

This isn’t the first study to link opioids to endocarditis and an increased risk of stroke.

For example, one study published in September 2016 in the American Journal of the Medical Sciences looked at one hospital’s admissions for endocarditis and found the proportion caused by IV drug abuse climbed from 14 percent in 2009 to 56 percent in 2014. This study also found opioid-related endocarditis associated with much longer hospital stays and more days in intensive care, both of which can drive up health costs.

And, a different study published in January 2019 in Stroke looked at U.S. hospitalizations for stroke due to endocarditis and opioid use over more than two decades. From 1993 to 2015, the rate of hospitalizations for strokes caused by opioid-related endocarditis surged from 2.4 to 18.8 cases per 10 million residents, the study found. Most of the surge occurred after 2008, over the same period that opioid abuse reached epidemic levels in the United States, this study concludes.

A separate study published in October 2020 in Clinical Infectious Diseases looked at more than 17,000 hospital admissions for endocarditis from January 2013 to March 2017 in Pennsylvania, a state hard hit by the opioid epidemic. Over this period, total quarterly admissions for endocarditis due to drug abuse surged by 238 percent, compared with a 6.5 percent increase for cases due to other causes. This study also found higher hospital costs for endocarditis cases due to drug abuse.

“If someone comes in with a history of IV drug use and has symptoms of a stroke, endocarditis needs to be considered as the cause,” says Carolyn Brockington, MD, director of the Stroke Center at Mount Sinai West and Mount Sinai Morningside in New York City.

How Endocarditis Damages the Heart

Endocarditis develops when germs enter the bloodstream, travel to the heart, and latch on to damaged tissue or abnormal valves, according to the Mayo Clinic. Common causes include poor dental care, which leads to bleeding gums that give bacteria a way to enter the bloodstream, catheters used to get fluids into or out of the body, and illegal IV drug use that often involves contaminated needles or injecting through unwashed skin.

When endocarditis develops, clumps known as vegetations can form an abnormal mass in the heart. Then, these vegetations can break free and travel throughout the body to the lungs, kidneys, arms, legs, or abdominal organs, according to the Mayo Clinic. Vegetations can also travel to the brain, resulting in a stroke.

“IV drug users risk infection when injecting themselves with opioids either by repeat usage of needles or injecting through skin that is not clean,” Nimjee says.

“Infections grow in the bloodstream and embed themselves on tissues, including heart valves,” Nimjee adds. “These colonies of bacteria on heart valves can break off and embolize in the brain, causing strokes.”

Stroke symptoms for IV drug users aren’t necessarily different from symptoms other people would experience, Nimjee says. Signs and symptoms of stroke can be summarized by the acronym BE FAST:

  • B — Balance: sudden dizziness, loss of balance or coordination
  • E — Eyes: sudden trouble seeing out of one or both eyes
  • F — Face: facial weakness, uneven smile
  • A — Arm: weakness, inability to move both arms evenly
  • S — Speech: impaired, slurred, difficulty repeating simple phrases
  • T — Time: Call 911 immediately

There are some specific stroke prevention measures that can help minimize the risk of endocarditis among IV drug users, Nimjee notes. While treating opioid use disorder could help, the most urgent thing is to provide IV drug users with access to sterile needle supplies and injection conditions.

“Needle exchange programs, like those developed to curtail the spread of HIV, can have an impact in preventing infection in the bloodstream,” Nimjee says. “However, even if an IV drug user does not share needles, the risk of infection remains if needles are reused or in an unsanitary environment.”

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