On the one hand, the young mother who came into the Kanawha-Charleston Health Department clinic in Charleston, West Virginia, last fall had good news for the doctors there: She’d been off heroin for four days.

Yet she was far from well. She had a painful dental abscess in her jaw that was causing yellow pus to drain out of her ear. She had hepatitis C. She’d recently missed her period and was worried she might be pregnant with her third child.

The staff at the clinic, which is also a needle exchange, told me they estimate that at least 70 percent of their patients who use intravenous drugs are seeking not just fresh needles but treatment for hepatitis C, which they developed during drug use and can cost $20,000 to $90,000 to treat per person. Others have another kind of dangerous infection called bacterial endocarditis, or a combination of the two.

The United States often measures the severity of its opioid crisis in drug overdose deaths. Driven by prescription opioids, heroin, and the deadly synthetic opioid fentanyl, drug overdoses claimed 64,000 lives in 2016 alone, more than the entire death toll during the Vietnam War.

But on top of the skyrocketing overdoses, there is a related public health crisis that’s largely overlooked and gravely underfunded. Opioid and heroin use is causing a dramatic spike in new hepatitis C infections, as well as dangerous bacterial infections that, if left untreated, can cause strokes and require multiple open-heart surgeries. Doctors and public health officials also fear America is on the brink of more HIV outbreaks, driven by intravenous drug use.

With the federal government slow to act, small needle exchange clinics like the one run by Charleston’s city health department are on the front lines, desperately trying to stop or slow the spread of these infections by treating them and encouraging patients to seek addiction treatment.

“This really is an epidemic of epidemics,” said Dr. Michael Brumage, the Charleston health department’s executive director. “The number of overdoses does not convey the full scope of the tragedy that’s playing out in front of us.”

Lawmakers and federal officials often cite $45 billion as the amount of money needed to treat the drug crisis, but experts say the real number to treat addiction and disease brought on by drugs is likely four times that. It would account for costs like curing hepatitis C ($20,000 to $90,000 per person) and open-heart surgery for bacterial endocarditis ($100,000 to $200,000). A bipartisan spending bill Congress passed last month contains $6 billion in funding for opioid abuse and mental health treatment, which local officials say is nowhere close to what’s needed.

With little help from the federal government, clinics like Kanawha-Charleston are badly underresourced in their fight against drugs and the diseases they cause.

“I feel like I probably just see the tip of the iceberg on this because I’m typically seeing the sickest folks in the hospital”

America’s opioid epidemic started in the 1990s and early 2000s when doctors began prescribing opioids for pain. Due to a combination of factors, including pharmaceutical companies pushing pills, doctors believing the drugs were safe, and incentives for a fast, efficient health care system that prioritized quick fixes, opioid prescriptions proliferated. The US is by far the leading prescriber of opioids in the world.

As prescriptions for addictive opioids like OxyContin became harder to come by, some people turned to heroin.

But the proliferation of intravenous drug use has led to a syndemic, or “multiple diseases feeding off of one another,” according to Tufts University public health professor Thomas Stopka.

One risk is infections from dirty needles, injection tools, and water to mix drugs. People often think of shared needles as the culprit for infection, but simply using the same needle or spoon to cook drugs multiple times is also a risk factor, as is not sanitizing skin or needles with rubbing alcohol.

Then there’s the matter of what’s actually being injected. Some drug users in Charleston use toilet water to mix their drugs, according to clinic staff. Sometimes, they’ll draw water out of the brown, silty Kanawha River, said Abdul Muhammad, 56, a local Charleston resident and drug user who attended a Narcan training session at the clinic this fall.

“A lot of people are careless,” Muhammad said, speaking of the young drug users he sees. “They don’t get the capacity of the dangers.”

When bacteria builds up in needles or in the cookers used to mix drugs, it gets shot into a person’s bloodstream along with the drug, where it can travel anywhere throughout the body. Bacterial infections like this are called endocarditis; they are most dangerous when they reach the heart valve, causing nodules of bacteria to build up.

“If the infection is left unchecked and undiagnosed, it can become several inches in length and width and look like a sail billowing throughout the heart chamber,” said Dr. Jonathan Eddinger, a cardiologist at Catholic Medical Center in Manchester, New Hampshire.

There are 40,000 to 50,000 new cases of bacterial endocarditis in the US each year, but it’s not known exactly how many come from injecting drug use. One study found the prevalence of drug-induced endocarditis and other serious infections nearly doubled between 2002 and 2012, from about 3,421 cases nationwide to 6,535.

What’s particularly worrying about the potential rise of these infections among drug users it that on average, they cost more than $120,000 per patient to treat. Out of the $15 billion hospitals billed to treat opioid patients in 2012, more than $700 million went to treating patients with infections.

Related Why some US cities are opening safe spaces for injecting heroin

Catholic Medical Center is one of the two main hospitals in New Hampshire’s largest city, and it has seen a sharp rise in bacterial endocarditis. In 2008, doctors saw one or two cases of infected heart valves per month. By 2016, that had risen to about eight to nine cases per month, Eddinger said.

“The number is probably enormous,” he said. “I feel like I probably just see the tip of the iceberg on this because I’m typically seeing the sickest folks in the hospital.”

Sometimes patients require multiple complicated surgeries, including open-heart surgery, with no guarantee that one will be enough if the patient can’t stay clean.

Endocarditis patient James Pernal found that out the hard way, after about six or seven years of IV drug use. Vox contacted Pernal on the online forum Reddit after he wrote about his experience on a page for people who had experienced bacterial endocarditis. When Pernal messaged back, he was in still the hospital, recovering from his latest bout of the infection. Earlier in the year, endocarditis had given him his first stroke and nearly killed him, he said.

“When I got to the hospital I was rushed to ICU,” Pernal wrote. “Had no idea I had a vegetation growing in my mitral valve. It ended up going into my brain causing the stroke.”

“You don’t really feel anything from endocarditis,” he added. “It’s not painful, but after being on antibiotics in hospital for a month, the corrosion and plaque on the exterior of my heart traveled to my foot, causing it to turn purple and look like Freddy Krueger’s face. They said it could have gone to my internal organs and killed me overnight so I was lucky it just went to my foot.”

If caught early enough, an infection can be cleared up with an intensive regimen of antibiotics. But if it gets worse, patients as young as 20 or 30 are at risk of stroke. Doctors have to perform open-heart surgery to replace the infected heart valve, which can cost between $100,000 and $200,000. Patients often don’t see a doctor until they realize something is seriously wrong with them, which is complicated by stigma or fear that the police could get involved, Eddinger said.

“We don’t get them regularly until they’re very ill,” he said. “They’re embarrassed, quite honestly.”

After his stroke and the infection in his foot, Pernal couldn’t walk for a few weeks, and he eventually had to have open-heart surgery so that doctors could repair his damaged valves. Pernal estimated he spent a third of 2017 in hospitals from an infection he got from dirty needles.

“Mostly, people get it from dirty needles,” he wrote. “I can’t stress using a clean needle each time you dose. Honestly though I’d stress not even to go IV route. It’s not worth the damage it can do. It’s a way bigger issue than addicts think. Everyone thinks it won’t happen to them, but it can and will.”

Cases of hepatitis C associated with intravenous drug use are rising too

Another serious unintended consequence of the opioid crisis is the fast-rising rate of hepatitis C, a virus that spreads quickly through dirty needles. The United States has seen a threefold increase in hepatitis C cases over the past five years; the number of new cases rose from 853 in 2010 to 2,436 in 2015, according to the Centers for Disease Control and Prevention.

The opioid crisis has spurred a dramatic rise in hepatitis C infections, especially among younger users. Between 2004 and 2014, there was a 400 percent increase in hepatitis C infections in Americans ages 18 to 29, according to the CDC. There’s a similarly bleak picture for people ages 30 to 39, with a 325 percent increase in infections.

New research by the CDC suggests that this spike in hepatitis C infection rates is associated with a rise in intravenous drug use. As government researchers analyzed national and state data, they found infection rates rising at a similar trajectory to hospital admissions for opioid injection.

Part of the reason hepatitis C rates are spiking so much is the virus is much more resilient than other viruses like HIV. Whereas the HIV virus dies quickly outside the body, the HCV virus (which causes hepatitis C) can survive longer and therefore is easier to transmit. If left untreated, hepatitis C can cause liver cancer or cirrhosis.

In West Virginia, the state arguably hardest hit by opioid addiction, hepatitis C cases have tripled in just the past three years, according to Dr. Rahul Gupta, West Virginia’s health commissioner. Rural areas had more than double the rate of cases as in urban areas, according to a 2015 report from the CDC.

The good news is that there is a cure for hepatitis C; the bad news is that the cheapest course of treatment costs more than $20,000 and ranges all the way up to $90,000. Therefore, many state Medicaid programs have strict rules around paying for treatment.

One of the first patients at the Kanawha-Charleston clinic on a rainy fall day had recently discovered he was positive for the disease. (Clinic staff estimate 70 percent of the patients who come in have contracted hepatitis C through IV drug use.)

The man was soft-spoken and polite, with shaved silver hair, weathered skin, and holes in the knees of his jeans. He was carrying a black messenger bag full of used needles, which tumbled out into a plastic collection box when he turned it upside down. He asked clinic volunteer Sarah Embrey whether his insurance would pay for the hepatitis C cure. Embrey, a local pharmacist, looked at his state Medicaid card.

“You’ve got to be clean,” she told him.

West Virginia’s Medicaid program only pays for it once in a person’s lifetime, and if the patient is addicted to opioids, he needs to demonstrate he’s been sober before insurance pays for the cure.

The man nodded. He said he had recently kicked heroin but was still shooting crystal meth.

“I feel like that was a big step,” he said.

“Syndemic” diseases feeding off each other cost our health system billions of dollars

It costs tens of thousands to perform open-heart surgery on a patient who has bacterial endocarditis. And there’s no guarantee one surgery will be enough if patients continue to inject drugs. Eddinger has seen the same person in for a heart valve replacement multiple times; in fact, 25 percent of endocarditis patients in his hospital are repeat patients, about 250 over the past five years.

Not only is surgery costly, but the risk of complications goes up each time one is performed. The risk “goes up exponentially as they go in, and these folks aren’t coming in healthy to begin with; they’re coming in sick,” Eddinger said.

For all these reasons, University of Kentucky researcher Dr. Laura Fanucchi is adamant that evidence-based treatment like Suboxone, therapy, and counseling need to be offered to bacterial endocarditis patients, so that there’s less of a chance they’ll land back in the hospital in need of a second surgery.

A second bout of endocarditis “is often worse than the first, and these are young people,” Fanucchi said. “It’s devastating.”

With little help coming from the federal government, needle exchanges are racing against time

Public health officials across the country are fearful that the drug crisis could precipitate an HIV outbreak. This happened in Indiana in 2015, when about 190 people were diagnosed with HIV from shared needles. The outbreak convinced the state’s then-governor, Mike Pence, to allow needle exchanges to open up access to clean needles. It helped get the state’s crisis under control, but even so, the cost to the state was vast.

Officials estimated each patient diagnosed with HIV would take $1 million of state money when health care and public assistance was factored into the total cost. That meant taxpayers were looking at paying at least $190 million to take care of 190 people. And that’s just in one state.

Needle exchanges serve a dual purpose: making sure drug users are injecting with clean equipment to prevent infection, and getting dirty needles off the streets and disposed of properly. There is a collection box outside the health department that can hold 38 gallons of needles; it was full in the first five days. Once Charleston city officials collect the needles, they have a machine that sanitizes and crushes them up, turning them into small pieces of plastic that can be disposed of.

The Charleston health department only runs the clinic for five hours per day, one day per week, typically seeing about 400 people in that time. Most people come in for the clean needles, cookers, and cotton swabs, while others are seeking medical attention.

Needle exchanges are controversial because some people believe they enable drug use, but multiple studies have found them to be effective at reducing infection rates among drug users. In Charleston, the city’s needle exchange has partnered with local doctors and behavioral health specialists to provide even more services to the local population — treating flesh wounds and infections in the clinic and trying to get drug users into treatment.

The price tag often cited by the White House and Congress to treat America’s opioid crisis is $45 billion — though there’s little sign that amount will ever be allocated. And experts say that’s just a quarter of what’s needed. If you take into account the costs of treating the diseases associated with addiction like hepatitis C and bacterial endocarditis, the number is closer to $186 billion over a decade, according to Dr. Richard Frank, a health economist at Harvard.

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This gets to another problem public health providers are seeing: It’s much easier to get addicted in America than it is to get clean. A 2016 report by the surgeon general found that just 10 percent of Americans with a drug use disorder obtain specialty treatment.

Clinic staff in West Virginia can hand out clean needles, treat wounds, and encourage people to seek treatment, but in many states, there are not enough available beds at treatment facilities and not enough drug maintenance programs offering Suboxone or methadone to meet the needs of Americans with drug addiction.

Preventive and harm reduction programs like the Kanawha-Charleston clinic in West Virginia cost money upfront, but if they are able to prevent the spread of bacterial endocarditis, hepatitis C, and HIV in their area, they could ultimately save the taxpayers a lot of money in the long run, the Charleston health department’s Brumage said.

“If we prevent one to two cases of endocarditis, this program pays for itself,” he said.

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