The Washington University Infectious Diseases Division (ID) to open Infectious Disease/Substance Use Disorder training pathway to address substance use crisis in the region. The opioid epidemic and subsequent rise in injection drug use (IDU) has led to a well-described overlap of epidemics, or syndemic, of substance use disorders (SUDs) and infectious diseases including serious injection-related bacterial/fungal infections (SIRI), HIV, viral hepatitis and sexually transmitted infections (STIs). The St. Louis region has been particularly affected, with the highest overdose rate and HIV transmission rate in the state. Over the past five years, the Division of Infectious Diseases at Washington University has been a leader in providing wholistic care to people who inject drugs. They now hope to train a new generation of doctors to care on the work.
The Problem
Over the last two decades there has been a dramatic rise in the rate of injection drug use, particularly related to the opioid epidemic and rising amphetamine crisis. Health systems continue to be ill-prepared to manage patients presenting with complications of substance use disorders. This results in high rates of premature discharges with incomplete antimicrobial courses, increased 30-day readmissions and ED visits, and unmanaged costs for the healthcare system. In addition, unaddressed substance use misses opportunities to improve ongoing public health epidemics, such as transmission of HIV, Hepatitis C and sexually transmitted infections. Because of the syndemic nature of the substance use epidemic in America, infectious disease physicians are uniquely positioned to be leaders in the care and management of patients with infections and comorbid substance use. In 2020, there was a call for action published in Clinical Infectious Diseases articulating the case for the creation of ID/Addiction tracks within ID fellowships and promoting dual fellowship training.
Why Washington University?
The St. Louis region has been disproportionately affected by substance use, with high rates of hospital admission related to complications of substance use. As the largest hospital in the region, Barnes Jewish Hospital and Washington University staff are uniquely positioned to address this health crisis. Barnes Jewish Hospital serves as both a safety net hospital for an urban, local population and a tertiary care institution for a substantial rural population from its considerable referral base, which means it sees a lot of patients and many who have substance use. This is in the midst of a rapidly evolving drug supply with toxicities that result in infections and high healthcare utilization (i.e., xylazine-related wounds complicated by skin and soft tissue infections and osteomyelitis).
Why now?
After many years of intentional work, the Infectious Disease division has created a team dedicated to caring for patients with infectious disease and substance use concerns. Intentional recruitment has brought on several physicians who have relevant experience and, in some cases, extra-board certifications in Addiction Medicine. This has led to important partnerships between divisions, facilitating treatment of complex diseases, such as hepatitis C and drug use during pregnancy.
The Washington University Division of Infectious Disease also has one of the only integrated ID-based bridge clinics in the country, named the Bridge to Health Program. This clinic offers wraparound services to those admitted to the hospital with infectious complications of substance use, bridging patient care back to longitudinal substance use providers. The Bridge to Health program is an innovative program with physicians, social workers, and health coaches linking patients from the inpatient setting to the outpatient clinic. More recently this group has been taking their care to the streets, partnering with Street Med STL to bring infectious disease and substance use care to unhoused people who need it most.
Given this success, the Infectious Disease division is hoping to recruit new trainees with a passion for infectious diseases and substance use disorder treatment. This next generation of doctors will have the unique opportunity of training with experts and thought leaders in this area.
Madeline McCrary, MD, assistant professor of medicine, infectious disease, is the director of this new taining pathway. Dr. McCrary specializes in clinical infectious diseases and addiction medicine with a special focus on the infectious complications of substance use, such as Hepatitis C and Serratia endocarditis, and related quality improvement initiatives. She enjoys working with people who use drugs to reach their health goals.
Track Associate Directors include Nathan Nolan, MD MPH MPHE and Laura Marks, MD PhD. Dr. Nolan specializes in clinical medicine and education, with a special focus on marginalized populations, including patients who use drugs and patients who are unhoused. Dr. Marks specializes in clinical infectious diseases with a special focus on infectious complications in people who inject drugs. The inception of Street Med STL can be traced back to the experience Dr. Nathan Nolan had during his fellowship training, working with Dr. Laura Marks, who was running the Bridge to Health Program.
To learn more about the Division of Infectious Disease at Washington University, in St. Louis, check out the division webpage. To learn more about the recently formed training track, see the overview here.