The Surgeon General’s opioid strategy

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{***Noah***}

Coming up on a special edition of Harvard Chan: This Week in Health…A conversation with the Surgeon General.

{***Jerome Adams Soundbite***}
(Four people will die from overdoses in the time that we’re having this conversation today. And so, that is what I’m focused on foremost.)

In this week’s episode: An in-depth interview with Vice Admiral Jerome Adams on America’s opioid epidemic.

He’ll share his priorities for addressing the problem-and how his family’s own experiences with addiction have shaped his strategy.

{***Jerome Adams Soundbite***}
(I want to empower all of America, providers and the public, to be able to advocate for the causes that are most important to them. And to folks who are in the audience and who are listening, I challenge you to think of one thing that you can do to help respond to the opioid epidemic. Because we’re not going to be able to solve this problem from Washington, DC.)

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{***Noah***}

Hello and welcome to Harvard Chan: This Week in Health, it’s Thursday, February 1, 2018. I’m Noah Leavitt.

{***Amie***}

And I’m Amie Montemurro.

{***Noah***}

On this week’s episode we’re doing something a little bit different.

We’re sharing a conversation from the Voices in Leadership interview series here at the Harvard Chan School.

{***Amie***}

Each semester, the program welcomes global leaders to come to campus and share leadership lessons with students, staff, and faculty.

{***Noah***}

And Voices in Leadership recently hosted Vice Admiral Jerome Adams, the 20th Surgeon General of the United States.

{***Amie***}

The Surgeon General is often considered the country’s “top doctor”-but they’re also the nation’s top public health official.

In his role, Adams serves as the principal adviser to the Secretary of Health and Human Services on a range of public health and scientific issues.

{***Noah***}

And at the top of Adams’ agenda is the country’s opioid epidemic.

During a conversation with Robert Blendon, Richard L. Menschel Professor of Public Health here at the Harvard Chan School, Adams discussed his strategy for addressing opioid addiction.

{***Amie***}

He also spoke about how his family’s own personal experiences with addiction have informed his work.

{***Noah***}

And just a note that later in the interview you’ll also hear from Monica Bharel, who is the State Health Commissioner in Massachusetts-who is leading efforts to address the opioid epidemic in that state.

But now we’ll jump into the conversation between Robert Blendon and Vice Admiral Jerome Adams.

{***Jerome Adams Interview***}

ROBERT BLENDON: Bob Blendon. This is going to be a very special event because it actually cuts across two issues. One is the role of the surgeon general leadership. The second is a very shared involvement with the opioid abuse epidemic, of which he’s playing a national role. But also in our audience is the State Health Commissioner Monica Bharel and former governor Ted Strickland. And these are issues that they have all been involved with, and we will have some exchange.

Also, I am guilty, for the Boston Globe, of having polled numerous times on this issue and worried about this. So we have, sort of, had two sets of discussions. We could solve the opioid problem, or we could also talk about being surgeon general. So we’re going to split for that.

One is, as 20th surgeon general, secretly, the Department of HHS has grown 50 times over the last 20-some years. And a lot of people are not familiar with the role that the Commissioned Corps plays– the surgeon general. There is a unique role that goes, And so I thought we just would start out by your summary of the unique role, some of your priorities about how you will use that role to try to have an impact, and then we’ll switch to the broader discussions about the surgeon general’s leadership in what has become sort of the public crisis at the moment across the country.

JEROME ADAMS: Great. Well, thank you, Bob. It’s good to be here. Dr. Johnson, thank you for your leadership in facilitating this series. And thank you to everyone in the room and who’s joining us today as part of this discussion.

I would start off, and I’m prone to do this, I’m going to begin with the ending because I want to make sure that anyone who breaks off early for lunch gets the take-home point, since this is a Voices in Leadership series. Everything that I’m going to talk about today is informed by a set of core beliefs that I have. And those core beliefs resonate around, number one, we need to make sure we know and are speaking to our audience. We’ve got to do a better job of that. And the governor, certainly, can appreciate that.

Number two, we’ve got to make sure we understand the difference between science, and this is my little Venn diagram here, and policy. And we’ve got to understand that they don’t always overlap. What we’re looking for is that sweet spot where they do overlap.

And number three– and this is one of the reasons why I’m so pleased to be up here with you, because this is your area of focus– we’ve got to do a better job promoting the science of influencing policy, figuring out how we can be more effective, and not just beating people over the head with science, science, science, and doing what Einstein said is insanity– doing the same thing and expecting a different result.

So now, I’ll get into your question, briefly. What is the surgeon general? Well, I’ve got three roles. Number one, the one that people are most familiar with, is that role as the nation’s doctor. And, in that capacity, it is my job to communicate the science around health to the American people very, very, very succinctly.

Number two, I’m an advisor to folks within the administration and within other agencies, a content expert, if you will, at their leisure. Number three, and this is the only one that’s actually written in statute, I’m the head of the United States Public Health Service. That’s why I get to wear this uniform. It’s not because I’m an airline pilot, even though, flying in today, everyone thought I was an airline pilot. You do not want me flying your plane.

But as head of the United States Public Health Service, I’m in charge of 6,500 uniformed officers who are all dedicated to health– nurses, doctors, pharmacists, environmental health officers, people with degrees in public health, all dedicated to promoting and protecting the health of not only the United States but of the world. We’ve had people deployed to September 11 response. We had over 1,000 officers deployed to the three Category 5 hurricanes we had in a row. And I had the pleasure of seeing them really thrive in their response to the hurricanes in Texas and Florida and Puerto Rico and the US Virgin Islands.

We’ve had folks respond to the Ebola outbreak. And we were the only uniformed service that actually provided medical care and response to the Ebola outbreak. And so, I’m really proud to be able to wear this uniform. I’m proud of what it represents. And I hope to be able to leverage the folks in the United States Public Health Service to continue to promote and protect the health, again, of not only the United States but in the entire world.

ROBERT BLENDON: So we talked about before, when you take on a leadership position, you have a small number of priorities. What are your priorities? What would you really think, over the next few years, you really want to move this country to do?

JEROME ADAMS: Well, I’ll hit them very quickly, and then we can dig into them a little bit more, if you’d like to. Number one, obviously, is the opioid epidemic. We’ve got a crisis going on– four people will die from overdoses in the time that we’re having this conversation today. And so, that is what I’m focused on foremost.

Number two, I want to focus on showing the link between health and the national economy, the premise being that our nation’s poor health is a drag on our nation’s economy and our nation’s prosperity. We know that the top issue people vote on, Democrat or Republican, more often than not, is jobs and the economy. So how can we help folks understand that focusing on health will really help them promote the economy, bring jobs to their community, and again, ultimately, for us to accomplish the things that the voters want us to accomplish?

And then, number three, I’d like to focus on health and national security. Bob, seven out of 10 of our 18- to 25-year-olds are ineligible for military service in the United States, mostly because they can’t pass the physical. So our poor health is not a matter only of diabetes 20 years down the road or a heart attack 30 years down the road. We are a less safe country right now because we are a less healthy country than what we know we could be and should be.

And if I can get any progress in helping folks understand the link between health and the economy, health and national security, and hopefully turning the tide on the opioid epidemic, I will have considered my time in this role a success.

ROBERT BLENDON: So let’s just do one sort of personal experience question, and then I want to move to the opioids. And that is, life moving from a commissioner in Indiana to Washington– there must be some impact on how you see yourself, life, and experiences. So what was the transition like, beyond the moving efforts?

JEROME ADAMS: Well, you say, “beyond the moving.” I moved from middle America, from Indiana, to Washington DC. So that was a big difference. And as a poller, you know that people poll very differently on all sorts of issues in middle America than what they do here on the East Coast. So that, in and of itself, was a big change. The traffic was terrible. Big change there.

But as far as the roles go, as a health commissioner, I had a whole lot more authority and autonomy to implement programs. The levers that I had to be able to effect change are different. And this is important for folks who are interested in health. There are so many different roles you can go into. You can be a physician– and again, I’m a practicing physician– and help individual patients. You can go upstream and do public health.

But within the field of public health, I had over 900 people who were working for me. I had people in public affairs. I had people doing HIV. I had people doing maternal and child health. And so, the point being, there are different roles you can play. And I had a lot more direct operational authority as the state health commissioner.

As surgeon general, I don’t have control over direct programs outside of the Corps. But I do have the ability to help educate the public and raise up the importance of various issues like never before. And that’s one of the reasons that I’ve shared the story about my brother, who suffers from addiction. I’ve been very open about the struggles my family faces because I want folks to understand that the problems we’re talking about aren’t problems that affect one person or those people. They affect all of us.

ROBERT BLENDON: So let’s move in to the issue, I think, that has captured the country and you and everything else. Where, in your view, do we have to go with the opiate issue? Where does the surgeon general– the pivotal, critical point you see, moving ahead?

JEROME ADAMS: Well, again, my number one job is to educate the public regarding the science of health. And there are three areas that I’m focused on. Number one is naloxone, increasing the availability of naloxone. People have been misusing substances since the beginning of time. So why is it now an epidemic? It’s an epidemic because people are dying like never before.

And as a physician, when people are dying, when you come across a trauma scene, you’ve got to put on a tourniquet. Naloxone is that tourniquet. We’ve got to help folks understand– you just put out a paper where 52% of people don’t think naloxone should be available without a prescription. 52 percent of people wouldn’t say that you shouldn’t know how to do first aid at a scene when you come upon an accident. We’ve got to help folks understand that the naloxone saves lives and that it’s a critical first step to connecting people to care.

Number two, focused on educating the public about the severity of the epidemic and steps that they can take to respond, both from a prevention point of view and– I’m a father of three young kids. I’m interested in how do you stop, how do you prevent, addiction in the first place? But I’m also the brother of someone who suffers from addiction. How do you help people find appropriate treatment if they do know someone who’s suffering from the epidemic?

And then, number three, focused on prescribing and prevention. As a physician, I feel like I have a unique ability to be able to speak to folks, to my fellow colleagues, and help them understand the role that they can play in helping us dig out from under this epidemic by following the CDC guidelines, by prescribing responsibly, by becoming trained in how to treat substance use disorder and getting DATA waivered, so that they can prescribe buprenorphine and methadone and naltrexone and the substances that we know, from an evidence base, help folks recover from opioid use disorder.

ROBERT BLENDON: So we’ve talked about this before. In the survey work we did, the most striking thing was how many Americans don’t know if there’s a treatment and what the treatment is. And so, he talked about his educating the public. We had 50 chiefs of clinical departments downstairs. He walked in, in a half-hour, had them realizing that they weren’t at all talking broadly enough in their own medical communities about this. So there are big audiences.

But I have to ask from the point of view that I interviewed, what exactly is it that we can do to treat people? Why isn’t it more widely available? And how would I know that there really are qualified people doing this? For those of you who follow the news, there are all kinds of suits going on of people who put their loved one in some sort of a treatment program, and there was no it there. And they don’t know how they were being protected.

So on behalf of the people that were surveyed, what is it that can be done? And how do we get this more available? And how do you know that it’s something that could work out for your family member or if I’m referring somebody for that? Notice, I only ask easy questions.

JEROME ADAMS: Exactly. Well, I’m going to give you both a supply and demand answer to that question. And I’m going to try to be brief. On the supply side, I call on my colleagues. And I say “my colleagues”– I’m not just talking about physicians, I’m talking about all health providers, everyone who is interested in health, to figure out how they can be part of the solution.

One of the things that I was saying to Bob earlier is that, in Indiana, we only train a handful of people each and every year to be able to provide specialty care in substance use disorder treatment. We’re never going to dig out from under this if we rely on just the folks who have specialized training and a residency to be able to respond. What we need to do is leverage the occupational health doctors, the family medicine doctors, the ob-gyns, the nurses, the therapists, all the army of folks that we have throughout our society. If we enable them and train them to be able to screen, to be able to do brief interventions, to be our gatekeepers– and then save the people who are trained in the specialty areas for only the really toughest cases.

Project ECHO was another great example of a way to train the trainer and extend care to hard-to-reach places. We’ve got to do a better job of enabling more folks to be able to respond because we can’t train people fast enough. What we need to do is take the people who are out there and enable them to be able to provide that care. That’s on the supply side.

But on the demand side, you ask a very important question. You ask, how do you know which treatment programs work? And I’m going to be honest, there’s a lot of bad treatment programs out there. But what shocked me about your paper that you just put out in the New England Journal was the statement that, in the poll, that about 50% of folks don’t believe there is an effective treatment for substance use disorder.

Let me be clear, Bob, treatment absolutely is effective, and it is the only way we’re going to dig out from under this epidemic. However, we need to help folks understand how to discern the fly-by-night charlatans from the effective treatment programs. And on the government side, one of the things that we’re doing is trying to compile a list. You can go to a substance abuse and mental health services agency website and find a list of providers in your area who, at least, have gone through an initial screening to be considered valid.

But we also have to be responsible consumers. If we are going to go out and buy a refrigerator, we’d go online. And if you all are like me, you’ll spend hours, you’ll spend days searching to find that right refrigerator or that right car or that right TV to watch the Super Bowl on next week. We need to be more responsible consumers.

And so, I’m going to tell you some criteria that folks can look to when they’re trying to discern what is an effective program. Number one, it’s got to be personalized. And what do I mean there? We know that every person’s addiction story is different. And you need to find a program that is going to evaluate, diagnose, and treat you based on your individual story and not try to throw a one-size-fits-all approach at you. If they do that, it’s probably not going to be effective.

Number two, you need a program that offers a full array of FDA-approved options and medications. Because, unfortunately, only one in three treatment programs offers what we know to be the standard of care, and that’s medication-assisted treatment.

And a lot of folks will say, but I know plenty of folks who’ve recovered without medication. Well, I also know plenty of folks who’ve recovered from their diabetes without medication. But that doesn’t mean that I’m still not going to provide insulin in my clinic if I’m an endocrinologist. It doesn’t mean I’m not going to provide asthma medication for someone in my pulmonary clinic simply because I know folks who’ve been able to deal with it with behavior change.

So you want to make sure you have that full array. You want to make sure you have access to behavioral interventions. Because some of the bad clinics are the ones that only give out medication. And it’s medication-assisted treatment. It’s got to be the full array of treatment.

We want to make sure we’re treating comorbidities, such as hepatitis, such as HIV, such as cardiovascular disease. Because you’re not going to be able to be compliant with your treatment if you’re worried about your other, untreated illnesses.

We want programs that make sure they look at addiction as a chronic disease. Again, some of the fly-by-nights will come in, detox you, and then put you back out on the street. Well, we know from a long history of success with treating folks who have addiction to alcohol that recovery takes a lifetime. And yes, it may start with inpatient treatment, but there needs to be a lifetime of outpatient support if we want people to be successful.

And then, finally, good programs need to have a full array of recovery support services. Again, you’re not going to be successful if you don’t have a home to live in, if you don’t have food to eat, if you don’t have a job to go to. So good programs should have referrals or connections to recovery support services so that they’re not just getting you, medically, in an appropriate place, but they’re wrapping you in an environment that’s going to ensure your success long-term.

ROBERT BLENDON: Dr. Bharel, I was going to ask you– can we have a mic?– from a Massachusetts point of view, does it look any differently? Or is that exactly the issues that you’re trying to pursue?

MONICA BHAREL: Well, you know, first, thank you to Dr. Adams for being here. I’d like to join the school, and come back home to the school, and welcome you to Massachusetts. It’s wonderful to have you here. And, you know, as I was just listening to you speak, the framework you use is very much how we think about the opiate epidemic here in Massachusetts and how we have framed our approach to it.

You know, you spoke about the magnitude of this epidemic and why we all are responding this way. And we’re talking about numbers. And, as you suggested, behind each one of these numbers is a person. And in Massachusetts, we’re losing almost six people a day. And that is obviously devastating to lose the individual. It has effects on their family, their loved ones, their communities. I bet there’s nobody in this room who hasn’t had personal or professional experience with this epidemic.

In Massachusetts, we haven’t seen this kind of death rate from a single disease since the beginning of HIV. So this has really been a call to action for us here in Massachusetts, as you’re describing it nationally. And for the last several years in our administration, it’s been our primary public health priority to respond to this opiate epidemic. And we framed it similar to the way you’re talking about it. So we frame our interventions around prevention, intervention, treatment, and recovery.

And in the prevention area, as you’ve suggested, we’ve found it very important to go upstream and do primary prevention– so making sure that individuals understand the risk of the opioids and the ways in which this opiate epidemic is different than addiction issues in the past. We’ve run several campaigns. And one of the interesting parts for me, and really important focuses, has been on stigma.

You alluded to this, but how we, as communities, think about things such as asthma or diabetes or hypertension and the treatments and capacity for people to recover versus, from your polling results, how we think about substance use disorders– we’ve done a lot of work in that area. And as I go across Massachusetts, I’m so happy to see, really for the first time, people talking about substance use disorder as the disease that it is and not a choice or a moral decision.

You talked about prescribers and how important it is to think about how much opioids are in our communities, and how are individuals educated? And, you know, when you and I were in medical school, we didn’t get enough training on how to treat substance use disorder. And in Massachusetts, we’ve changed that. So now in Massachusetts, to graduate from medical school, dental school, nursing school, physician assistant school, or social work school, you have to have training in how to balance the need for pain management with potential for opiate misuse. So starting to train that next generation you spoke about.

And, additionally, we’ve put in place the prescription monitoring program. So that has to be checked every time. We’ve revamped it to make it, for those of us who have practiced clinical medicine, to make us capable to use it in clinical settings. And we’ve seen a 29% decrease in the number of opioids in our community, so that’s a decreased burden and exposure to the medications.

We’ve really worked on this issue around naloxone. I’m going to use your tourniquet example, because I think that really is a vivid way to think about it. People worry about naloxone not being the answer. And as you talk about, I talk about it, just like when someone comes into the emergency department with an asthma exacerbation. Of course, we’re going to give them the albuterol that they need. We need to think about what’s happening in that moment, and then do the maintenance drugs. So we’ve really worked to make sure that naloxone is available to family and friends, through pharmacies, through providers, as well as our first responders, so fire and police have been an incredibly important partner for us in this.

And I know when you talk, you talk a lot about cross-sector work, inside and outside of public health, and really reaching across borders to educators, police and fire, criminal justice. And working together on these issues has been key for us. And then, finally, in treatment and recovery, I couldn’t agree with you more. We know that medication works for this medical disease.

And when people ask me, what are the obstacles? The biggest one, to me, really, is still stigma among us as prescribers, as well as the general community. And then, access. And we’re really working hard to increase the availability of providers who can prescribe buprenorphine. And the federal changes on that have been very helpful, to be able to have more patients who have buprenorphine. But we also want individuals to feel more comfortable addressing the needs of those with substance use disorder. And we’ve worked a lot on that, too.

And then, finally, in recovery, I couldn’t agree with you more around making sure we address the social determinants of health. So we have worked to help set up a voluntary sober home certification program in Massachusetts. So we have thousands of beds where individuals can go. And, as we oversee the substance use services in Massachusetts, we really are doing it with an eye towards– in our licensing and regulation, doing just what you said– making sure that medication is coupled with counseling, that people get the supports they need, thinking about ways that recovery coaches, peer-to-peer support, et cetera, can be used in that.

And all of this– last point– and I know you have an interest in thinking about the data, as well. And we really, in Massachusetts, have done a deep dive, looking across state agencies at whatever data we have on how individuals suffering from substance use disorder get to the point where they are. And we’ve targeted our response to areas.

And one of the things I found most profound, related to what you were saying, is that we know in Massachusetts, if you put somebody on medications when they have a non-fatal overdose, their risk of death goes down by 50%. So we have the evidence locally, as well as in peer-reviewed literature.

ROBERT BLENDON: Let me just get back in and say, just because of the time, so for history point of view, the number of times the surgeon general has talked to the state commissioner about these issues is very, very few. This event, where people actually interact, doesn’t often occur. You have statements from people in Washington, you have people in the state, who wonder if I can ever have a discussion about what we’re doing.

So the fact that, A, that we could use the event to really look at what Massachusetts is doing– and also, the surgeon general has a broader point of view. Because we would like future surgeon generals to actually spend time talking to people at the state level. And the fact that he was at the state level before he did this realizes that there is this up here. And then, at the same time, you have to be able to relate to people on the ground making these decisions.

So let me give you one shot here. I’m learning this. I did something with someone formerly at ABC News, and I was told I was allowed to talk for 15 minutes. And I got there, and they said, you had two. So I’m practicing on how we can move from the 15 to two.

So we need, sort of, a close of your vision about if you’re looking back, the one or two things you want to look back– because public life is always a temporary leadership role– and say, I did this. And I really feel incredibly good about it. What are the one or two things you want to look back at?

JEROME ADAMS: Well, most importantly, I want to empower all of America, providers and the public, to be able to advocate for the causes that are most important to them. And to folks who are in the audience and who are listening, I hope you– I challenge you– to think of one thing that you can do to help respond to the opioid epidemic. Because we’re not going to be able to solve this problem from Washington, DC. We can certainly provide funding, provide expertise, lower barriers.

But at the end of the day, this problem is going to be solved on the community level, on the local level. And it’s got to be all hands on deck– everyone, the mother, the father, even the child. I tell my 12- and 11-year-old, you have a responsibility to educate your classmates about the dangers of opioids and the reason why we need to avoid it. Share the story about your uncle, who tried it once and is now in prison because of his addiction.

There’s a role for every single one of us to play. And if I can help folks be more effective advocates for the causes that they believe in, again, I will have had a successful tenure. And we will help across the board, whether it’s opioids or cardiovascular disease or diabetes or asthma or what versus focusing in on one particular disease and then seeing it pop up in other areas.

ROBERT BLENDON: So we’re going to thank our guest. But to say the very obvious, he’s an unbelievable, inspirational leader. And in terms of a physician teacher for America, we actually are very, very fortunate and privileged that we could share this today, for everybody today.

JEROME ADAMS: And Bob, one more thing I would add is that, soon we will be unveiling a “share your story” website via the White House. And you all may have heard the president share his family’s story of addiction at the Opioid Commission meeting. But I encourage you to go on that website and share your stories because only by helping everyone understand how this affects communities, and helping everyone feel enabled to come forward, will we get to where we need to be.

So thank you so much for the opportunity. Thank you all for joining us. And please reach out if there’s anything the Office of the Surgeon General can do to help you become a better advocate for the causes you believe in.

ROBERT BLENDON: You have been incredibly inspirational. Thank you very, very much.

{***Pause/Music***}
{***Noah***}

That was the conversation between Robert Blendon and Vice Admiral Jerome Adams on America’s opioid epidemic.

{***Amie***}

And we think this is an important conversation for people to hear-especially the Surgeon General’s call to action there at the end.

We’ve posted a Facebook video of the interview on our website, hsph.me/thisweekinhealth, and we’d encourage you all to go online to share this interview with your friends and family.

{***Noah***}

On our website you’ll also find some more information about the Voices in Leadership series. On February 6, they’ll be welcoming Ted Strickland, the former Governor of Ohio, for a discussion about mental health policy-focusing on a range of areas, including addiction, poverty, prisons, and guns.

{***Amie***}

In the meantime, you can always listen to older episodes of our podcast on Soundcloud, iTunes, and Stitcher.