Missing the forest for the trees: The world around us and surgical treatment of endocarditis.

There has been a dramatic increase in intravenous drug abuse (IVDA)-related deaths in midlife Americans. Nowhere is this more profound than in rural Appalachia, with Kentucky in the midst of the epidemic. The causes of this finding are multifactorial and likely related to social, economic, legal, and population factors. Evidence suggests that the economic middle class is shrinking. The traditionally white midlife demographic that used to comprise more than 80% of the US middle class now accounts for less than 60%. Along with this shrinking middle class come the inevitable trappings of poverty, including drug abuse. Population-based data reveal that the shrinking middle class is associated with a significant rise in drug abuse in the population that traditionally made up the middle class; that is, white, midlife Americans. In Kentucky, the drug of choice for abuse has changed during the past 2 decades, largely related to law enforcement and political efforts. Efforts to control drug abuse have, however, suppressed availability and use of 1 substance only to have another move to the forefront. For example, during this time abuse has shifted from methamphetamine at the turn of the century to narcotic pills during the early 2000s to intravenous injection of heroin beginning around 2010. Along with this shift in the drug of choice for abuse came an alarming trend in mortality associated with IVDA, both in Kentucky and nationally, including the need for surgical correction of IVDA-related endocarditis. Thoracic surgeons have tended to avoid or ignore the greater problems that caused the epidemic of IVDA-related endocarditis. Perhaps it is time for thoracic surgeons to give a stronger voice to the societal issues that loom in the background of this epidemic.