Ensuring Fair Management of Infective Endocarditis in Patients with Substance Use Disorder

Maureen Kelley, PhD – Wake Forest University School of Medicine; Ana Iltis, PhD – Wake Forest University

Abstract: As the opioid epidemic persists in the US, the incidence of substance use disorder (SUD) and, consequently, infective endocarditis (IE) from injection drug use continues to rise. Despite advancements in treating IE, patients with SUD often face stigma and systemic barriers that influence clinical decision-making. Concerns surrounding treatment adherence, resource allocation, and relapse risk can lead to care restrictions that are not typically imposed on other patient populations.

While harm reduction strategies—such as medication-assisted treatment and safe use initiatives—can complement care, they often encounter resistance outside of addiction medicine and public health. Clinicians may struggle with the tension between reducing immediate harm and concerns about enabling risky behaviors, while some argue that harm reduction undermines recovery aspirations.

Emerging neuroscience also challenges traditional notions of patient autonomy and accountability, complicating the justification for patient contracts and treatment conditions. If SUD impairs volitional control, to what extent should patients be held responsible for their behavior? Should this shift our ethical framework for informed consent and treatment eligibility in the management of IE?

This presentation will explore these tensions, using case examples, addressing: (1) social justice and fairness, including how bias and structural inequities shape treatment access and clinical decision-making; (2) harm reduction and its role in patient-centered care; and (3) questions of responsibility, the use of patient contracts, and the implications of a biological model of addiction. These considerations will inform recommendations for improving care for patients with SUD and IE.

Keywords: substance use disorder, infective endocarditis, fairness