Ms. D, a 34-year-old woman with severe opioid use disorder (OUD), was admitted to an academic medical center for elective replacement of her prosthetic tricuspid valve. Three years prior, she had undergone prosthetic valve replacement for methicillin-susceptible staphylococcus aureus endocarditis, which required urgent intervention due to the presence of large vegetations and severe tricuspid regurgitation. After her first episode of endocarditis, she continued to inject fentanyl. She developed three additional episodes of IDU-associated prosthetic tricuspid valve bacterial endocarditis, as well as several episodes of culture-negative endocarditis, for which she received antibiotics. She tried methadone and buprenorphine-naloxone as medications for opioid use disorder (MOUD), and they did not initially reduce her non-prescribed opioid use. About 2 years later, in the setting of increased attendance at her methadone maintenance program, she stopped using injection opioids. Around the same time, she began developing progressive dyspnea. She had an outpatient echocardiogram, which revealed recurrent severe tricuspid regurgitation with a flail prosthetic valve leaflet and worsening right ventricular systolic function, without evidence of active endocarditis. She thus underwent evaluation for a prosthetic valve replacement. Ms. D’s past medical history was otherwise notable for chronic hepatitis C and septic pulmonary embolism, secondary to IDU, as well as left heart failure with preserved ejection fraction, thought to be attributable to IDU as well as obesity. Mental health conditions included depression, anxiety, and post-traumatic stress disorder. She lived with her husband in an apartment. Her family history included alcohol and cocaine use disorders, as well as unspecified mental health disorders in her mother and sister. Her substance use history included intranasal and injection use of fentanyl and cocaine, with a lifetime history of two opioid overdoses, once requiring naloxone. She smoked several cigarettes daily and occasionally used cannabis. When she first started MOUD with methadone, she frequently missed doses. However, at the time of her evaluation for prosthetic valve replacement, she had been abstinent from non-prescribed opioids for 1 year. She was in good standing at her methadone maintenance program, where she was prescribed 77 mg methadone daily with 13 “take-homes.” Take-homes, doses of methadone that can be self-administered in an unobserved setting, are provided to clients demonstrating moderate adherence to methadone and stability in their recovery, and reduce the frequency with which clients must present to the clinic. Notably, Ms. D’s take-homes were issued in the setting of the Substance Abuse and Mental Health Services (SAMHSA) exception expansion policies implemented during the COVID-19 pandemic. This expansion allowed flexibility in prescribing take-homes to patients who were less stable in their recovery but were medically complex and at high risk for complications of COVID-19. Early evidence suggests that these expanded take-homes increase treatment engagement and patient satisfaction, with minimal negative consequences [, ]. Boston Medical Center’s Endocarditis Team, known as the “Endocarditis Working Group,” oversaw Ms. D’s evaluation for valve replacement. This team was developed in 2017 in order to promote evidence-based treatment for patients with IE and minimize the extent to which stigma influenced care for PWID, and includes multidisciplinary providers from cardiology, cardiothoracic surgery, addiction medicine, infectious disease, and neurocritical care. Ms. D was initially connected to the working group through her outpatient cardiologist. As part of her evaluation by the Working Group, Ms. D attended outpatient appointments with infectious disease, cardiothoracic surgery, and addiction medicine. She also saw her primary care provider, who was aware of the ongoing evaluation and was supportive. Based on Ms. D’s symptoms and echocardiographic findings, a valve replacement was recommended. Because she did not meet criteria for an urgent valve replacement (e.g., overt heart failure, heart block, ongoing infection despite appropriate antibiotic therapy, large mobile vegetation, recurrent embolic phenomena) [], but rather had compensated sequelae of prior IE, the Working Group was able to follow her longitudinally. They collaborated with her methadone maintenance program and assessed her stability in recovery, which included consideration of her “recovery capital” (family support, stable housing, time in recovery, among others) as well as her adherence to MOUD. After sequential evaluations, the Working Group team members determined that the benefits outweighed the risks of a procedural intervention. She thus underwent a transcatheter tricuspid valve-in-valve replacement, chosen instead of an open surgical procedure due to the risks of complications associated with second sternotomy. Ms. D was admitted to the hospital post-procedurally for monitoring, and at that time, her husband disclosed that she had stopped taking methadone 1 week prior, unbeknownst to her providers. The primary team called the addiction consult team for assistance, to whom Ms. D affirmed her wish to maintain opioid abstinence without the use of MOUD. Before an alternate treatment plan was arranged, she left the hospital via patient-directed discharge. The addiction provider from the Endocarditis Working Group, who had been in touch with the addiction consult team during the admission, reached out to Ms. D and scheduled close outpatient follow up. At her outpatient visit, Ms. D started oral naltrexone, per her preference. Shortly after, due to persistent opioid cravings, she began purchasing non-prescribed methadone while awaiting re-admission to a methadone maintenance program. The addiction provider collaborated with a local methadone maintenance program to expedite Ms. D’s admission to the clinic, and communicated frequently with Ms. D throughout this time period. Ms. D’s outpatient cardiology and psychiatry providers also followed closely, rescheduled missed appointments as needed, and provided transportation assistance. At that time, the Working Group did not have a patient navigator, thus care coordination fell to individual outpatient providers and their clinical staff. Ms. D unfortunately did not qualify for additional home support, such as a visiting nurse. While awaiting admission to the methadone clinic, Ms. D used intranasal fentanyl, which led to an overdose requiring naloxone reversal. After her non-fatal overdose, she successfully re-engaged in her methadone maintenance program. She has not had any additional episodes of endocarditis or worsening heart failure and remains on MOUD.