Six infections, three heart surgeries, more than $1 million in health care — and still he can’t escape his drug addiction

Cardiac doctors in San Francisco see it again and again: young people hospitalized with a deadly heart infection caused by injecting drugs.

Warning: This story contains images of explicit drug use and discusses addiction.

Austin Draper leaned back against a thin hospital pillow, gazing over at the clear liquid dripping into his veins.

“To think that I did something to myself to require all of this is scary,” the 35-year-old said in June.

After spending six weeks tethered to an IV line of antibiotics, Austin, who was now sober after years of drug use, was about to leave the hospital — but not without fear of what waited outside.

“I'm anxious about what's gonna happen,” he said. “Am I just gonna go back and start using again? If I did, I’d be disappointed.”

While relatively rare, cardiac doctors in San Francisco see it again and again: young people hospitalized with a deadly heart infection caused by injecting drugs. And given limited health care resources and the relentlessness of addiction, doctors often have to decide between performing demanding surgeries or refusing to operate, knowing that without care, the person could die from the infection.

Austin, an empathetic young man with a creative spirit who’s been lost in a cycle of opioid addiction for more than a decade, knows the condition better than most.

In the past four years, doctors have diagnosed Austin with the infection, called endocarditis, six times. They installed his first pacemaker when he was 30, opened his chest three times for heart surgeries, and amputated all but one of his toes. The cost of his care likely exceeds $1 million, according to experts, though Austin, who is on Medi-Cal, hasn’t paid anything.

And after each hospital stay, Austin has turned back to drugs.

Endocarditis is a life-threatening inflammation of the heart’s inner lining, typically caused by a bacterial infection. Though a mostly hidden consequence of the fentanyl crisis, the disease is increasingly striking people who inject drugs, as bacteria from dirty skin, needles or cookers enters the bloodstream.

In the United States, an estimated 40,000 to 50,000 people a year are given endocarditis diagnoses.

Nationally, endocarditis cases among patients with opioid addiction soared between 2011 and 2022. Local numbers are harder to come by, but over the past five years, doctors at Zuckerberg San Francisco General Hospital saw 425 cases of endocarditis. It’s unclear how many of those involved IV drug users.

Many endocarditis patients who use drugs are unhoused and mentally ill, making them more difficult to treat. Those who don’t get help for their addiction often return to using drugs — and are readmitted for repeat infections, leaving health care providers frustrated.

These professionals are in a fraught position, said Dr. Alyssa Burgart, a medical ethicist at Stanford University, trying to balance their limited ability to address broader societal challenges and the risks of high-stake procedures against the instinct to improve every patient’s health at all costs.

“We want to be able to help patients to live longer with a higher quality of life,” she said, “but these social issues — a lack of housing, poor access to mental health care, clean needles and substance-use treatment — really show up in these ethical dilemmas, because we can't control those other aspects.”

In Austin’s case, friends and health care providers have helped him secure permanent subsidized housing, prescribed medications to treat his addiction and sought to channel his energy into interests outside of drugs, including sewing and cooking.

In hopes of avoiding another bout of endocarditis, Austin regularly picks up fresh supplies of clean needles and carefully disinfects his skin before injecting. But efforts to encourage him to quit injecting fentanyl and ketamine altogether have, so far, been unsuccessful.

Although many fentanyl users smoke the powerful opioid, the city collects an average of more than 150,000 discarded syringes a month. Austin prefers to inject, because he’s grown accustomed to the practice, he said, and it offers a stronger high. He describes his addiction as “the perfect relationship,” one that makes him feel safe from the outside world.

“Imagine if you had a partner that no matter what you did, no matter how awful you were, they were always there for you. When I use (drugs), it’s the equivalent of that for me,” he said during his most recent hospital stay. “The whole world could be falling apart around me, and I would feel fine.”

Austin’s youth in Santa Monica was comfortable. His parents worked in entertainment, he attended a private high school, and he spent his spare hours skateboarding.

But that stability crumbled his senior year when the Great Recession hit. His family lost its home and his mother stopped working. Soon, both Austin and his parents fell deep into drug addiction. His mom got hooked on OxyContin and later transitioned to cocaine, heroin and fentanyl. Austin recalls that when he first overdosed, she sprayed Narcan up his nostrils to revive him.

Austin never earned his high school diploma and spent much of his adult life without a place to call home. Still, for several years, neither those setbacks nor a persistent heroin habit kept him from chasing two of his passions: food and farming.

In his early 20s, he lived and worked on farms in Northern California before becoming a server in a handful of Michelin-starred restaurants in San Francisco and Los Angeles. Between jobs, Austin joined the outlaw subculture of train-hopping, traveling the country by slipping into rail yards and climbing aboard freight cars.

He managed to work, travel and use drugs for several years. Eventually, though, it became untenable. By his late 20s, he was living off and on with his mom while regularly using fentanyl.

In 2021, Austin said, he began to feel so weak and exhausted that even small movements felt impossible. His breath became shallow and slow, he developed a fever, he struggled to eat and drink, and his limbs felt so heavy he could no longer rise from bed. His mom took him to a Los Angeles hospital, where doctors diagnosed him with endocarditis for the first time.

His infection was so severe that doctors replaced his tricuspid valve and implanted a pacemaker. Despite weeks spent recovering in the hospital, Austin continued to use fentanyl — and within months of his discharge he developed another infection.

Shortly after his second hospital stay, both of his parents and a grandmother died within a few weeks. His parents' deaths, which he suspects were related to their drug habits, left Austin with little support, sending him into a depression and fueling more drug use. Austin has four sisters, but he lost touch with most of them over the years.

Seeking a reset and hoping to reconnect with some friends, Austin decided to travel up to San Francisco the following year.

Homeless and continuing to inject fentanyl, Austin vividly remembers lying on a corner in the Tenderloin, unable to move or eat, when he was taken to the hospital and diagnosed with his third case of endocarditis.

This time, his heart was so imperiled that doctors prescribed a medication that narrows blood vessels to sustain blood pressure. Because of his poor circulation, his toes became gangrenous and had to be removed. This was in addition to another open-heart surgery to replace Austin’s heart valve and pacemaker.

Yet Austin did not stop injecting drugs. Since then, he has been hospitalized for endocarditis three more times — once in Mendocino County and twice more in San Francisco.

Following his treatment in Mendocino County, hospital staffers sent Austin directly to a residential addiction treatment program in Ukiah. There, he enjoyed the staff, the food and the organic gardening classes, which reminded him of his onetime passion. But after completing a 30-day program, he turned down an option to extend his time and returned to San Francisco, where he quickly relapsed.

This year’s case of endocarditis, his sixth, was caught thanks to his primary care provider, Adrien Barbas of the city’s health department. While reviewing the results of tests taken after Austin took a bad fall, Barbas noticed signs of an infection in his blood. To ensure he received the immediate care he needed, Barbas rushed to his apartment and drove him to the hospital.

“I don’t want his life experiences or whatever label is given to him to get in the way of what services he should receive or how people perceive him,” Barbas said. “I want to give people all of the chances they can to succeed.”

Seeing some doctors and nurses repeatedly, Austin said, has left him feeling sheepish, but he’s grateful that they’ve repeatedly saved his life.

“I’m just not ready to die,” he said.

Treatment for endocarditis typically entails six weeks of antibiotics, administered through an IV pump in the hospital, but more severe cases require surgery to repair or replace damaged heart valves.

Surgeries like those Austin has endured could cost about $200,000, according to Nora Volkow, director of the National Institute on Drug Abuse, a research agency funded by the federal government. That’s in addition to an estimated $100,000 or so for each six-week hospital stay on antibiotics.

Doctors almost always operate when presented with a severe first case of endocarditis, but there’s less consensus on how to handle drug users with repeat infections, who may require increasingly more complex and difficult surgeries that could result in poor outcomes.

Some view these interventions as a poor use of limited health care dollars and resources, arguing that performing surgery on a drug user may not have the same benefits as on a person who does not use drugs. But failing to operate on an endocarditis patient who needs surgery increases the likelihood that they will die from their infection.

Burgart, the Stanford medical ethicist, said doctors must weigh the risks, benefits and potential alternative approaches for each patient.

Dr. Glenn Egrie, a cardiac surgeon for Sutter Health in San Francisco, said he uses the “one-year rule.”

“Is a patient going to be alive and well — in whatever quality of life that is deemed acceptable for that patient? If they are, then you have to do (the surgery),” he said.

Egrie said some endocarditis patients travel hundreds of miles to see him after another provider refuses to perform surgery, citing drug use and one or more previous operations. In most cases, Egrie said, he disagrees with those calls, and he largely blames a failing health care system.

“If there’s no support for a patient and we don’t address the underlying cause, then are we surprised when a person comes back with another complication?” he said. “In a certain sense, we have failed that person.”

It’s possible for endocarditis patients like Austin to be prescribed medication and set on a path to recovery, Volkow said. But she said progress in linking people to addiction care during their hospital stays has been slow. And when a patient’s addiction or mental illness is severe, even robust efforts may not be enough.

Stanford Medicine psychiatrist Dr. Anna Lembke said those with severe addiction who are released from a hospital and return to an environment where drugs are accessible and cheap face enormous barriers to long-term recovery. Intensive, residential treatment away from such settings is required in some cases, she said.

“It’s not a moral failing” by people suffering from addiction, Lembke said. “We’re all products of our environments and our social networks.”

Austin said he agrees with this assessment but looks for ways to justify his continued use and his lack of interest in residential treatment. For instance, he says that he’s concerned he’d lose this housing if he went into residential treatment, which would not be the case.

His health care providers have cautioned that the danger of losing his life now surpasses the threat of losing his housing.

After Austin was homeless for nearly a decade, outreach workers helped him secure housing about two years ago. And earlier this year, in the weeks before his most recent hospital stay for endocarditis, he had moved into a new building on the edge of SoMa. His unit has a kitchen and private bathroom, and the building’s on-site nurse reminds him of doctor’s appointments while dispersing his medications.

Austin meets regularly with a therapist and receives a monthly injection of Sublocade, which is meant to reduce cravings and symptoms of withdrawal. He knows he’s at risk of repeat cases of endocarditis and has plenty of people encouraging him to seek treatment.

Before leaving the hospital in early June, there was hope in his voice. He had spent six weeks stitching new fabric patches and designs onto his clothing, reading books and journaling. He spoke earnestly about his ambition to replace drug use with gardening, create his own clothing line and secure a job.

“If I can do this, I know that there’s so much more that I can do and contribute to the community,” he said. “I really think I’d be the best version of Austin that has ever existed.”

In a journal entry, he scribbled: “The next step is to stop this abuse.”

But with addiction, sometimes the best intentions quickly fade.

Less than an hour after he returned to his apartment from the hospital, a Chronicle reporter found Austin sprawled out on the floor in a drug-induced sleep.

After waking up and regaining his senses, Austin told the reporter that he had discovered a batch of leftover fentanyl and ketamine in his bathroom while tidying up. Careful not to overdose, he split the drugs into two portions, heated one in a metal cap, drew the liquified substance into a syringe and injected it into his groin.

“I just couldn’t resist it,” he said. “In my head, (sobriety) sounds easy, but when it actually comes down to it, it's just incredibly difficult.”

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