U.S. Surgeon General Discusses the Opioid Epidemic
The Doctors Company’s 2018 Executive Advisory Board meeting—a gathering of some of the leading figures in medicine in the United States—featured a conversation between The Doctors Company Chairman and Chief Executive Officer, Richard E. Anderson, MD, FACP, and the United States Surgeon General, Vice Admiral Jerome M. Adams, MD, MPH.In this first of two articles highlighting key excerpts from the conversation, Dr. Anderson and Dr. Adams discuss the opioid epidemic’s huge impact on communities and health services in the United States.
Dr. Anderson: Dr. Adams, you’ve been busy since taking over as Surgeon General of the United States. What are some of the key challenges that you’re facing in this office?
Dr. Adams: You know, there are many challenges facing our country, but it boils down to a lack of wellness. We know that only 10 percent of health is due to healthcare, 20 percent of health is genetics, and the rest is a combination of behavior and environment. My motto is “better health through better partnerships,” because I firmly believe that if we break out of our silos and reach across the traditional barriers that have been put up by funding, by reimbursement, and by infrastructure, then we can ultimately achieve wellness in our communities.
You asked what I’ve been focused on as Surgeon General. Well, I’m focused on three main areas right now.
Number one is the opioid epidemic. It is a scourge across our country. A person dies every 12 and a half minutes from an opioid overdose and that’s far too many. Especially when we know that many of those deaths can be prevented.
Another area I’m focused on is demonstrating the link between community health and economic prosperity. We want folks to invest in health because we know that not only will it achieve better health for individuals and communities, but it will create a more prosperous nation.
And finally, I’m raising awareness about the links between our nation’s health and our safety and security—particularly our national security. Unfortunately, seven out of 10 young people between the ages of 18 and 24 years old in our country are ineligible for military service. That’s because either they can’t pass the physical, they can’t meet the educational requirements, or they have a criminal record.
So, our nation’s poor health is not just a matter of diabetes or heart disease 20 or 30 years down the road. We are literally a less safe country right now because we’re an unhealthy country.
Dr. Anderson: Regarding the opioid epidemic, what are some of the programs that are available today that you find effective? What would you like to see us do as a nation to respond to the epidemic?
Dr. Adams: Just yesterday, I was at a hospital in Alaska where they have implemented a neonatal abstinence syndrome protocol and program that is being looked at around the country—and others are attempting to replicate it.We know that if you keep mom and baby together, baby does better, mom does better, hospital stays are shorter, costs go down, and you’re keeping that family unit intact. This prevents future problems for both the baby and the mother. That’s just one small example.
I’m also very happy to see that the prescribing of opioids is going down 20 to 25 percent across the country. And there are even larger decreases in the military and veteran communities. That’s really a testament to doctors and the medical profession finally waking up. And I say this as a physician myself, as an anesthesiologist, as someone who is involved in acute and chronic pain management.Four out of five people with substance use disorder say they started with a prescription opioid. Many physicians will say, “Those aren’t my patients,” but unfortunately when we look at the PDMP data across the country we do a poor job of predicting who is and who isn’t going to divert. It may not be your patient, but it could be their son or the babysitter who is diverting those overprescribed opioids.
One thing that I really think we need to lean into as healthcare practitioners is providing medication-assisted treatment, or MAT. We know that the gold standard for treatment and recovery is medication-assisted treatment of some form. But we also know it’s not nearly available enough and that there are barriers on the federal and state levels. We need you to continue to talk to your congressional representatives and let them know which barriers you perceive because the data waiver comes directly from Congress.
Still, any ER can prescribe up to three days of MAT to someone. I’d much rather have our ER doctors putting patients on MAT and then connecting them to treatment, than sending them back out into the arms of a drug dealer after they put them into acute withdrawal with naloxone.
We also have too many pregnant women who want help but can’t find any treatment because no one out there will take care of pregnant moms. We need folks to step up to the plate and get that data waiver in our Ob/Gyn and primary care sectors.Ultimately, we need hospitals and healthcare leaders to create an environment that makes providers feel comfortable providing that service by giving them the training and the support to be able to do it.
We also need to make sure we’re co-prescribing naloxone for those who are at risk for opioid overdose.
Dr. Anderson: So just so we are clear, are you in favor of regular prescribing of naloxone, along with prescriptions for opioids? Is that correct?
Dr. Adams: I issued the first Surgeon General’s advisory in over 10 years earlier this year to help folks understand that over half of our opioid overdoses occur in a home setting. We all know that an anoxic brain injury occurs in four to five minutes. We also know that most ambulances and first responders aren’t going to show up in four to five minutes. If we want to make a dent in this overdose epidemic, we need everyone to consider themselves a first responder. We need to look at it the same as we look at CPR; we need everyone carrying naloxone. That was one of the big pushes from my Surgeon General’s advisory.
How can providers help? Well, they can co-prescribe naloxone to folks on high morphine milligram equivalents who are at risk. If grandma has naloxone at home and her grandson overdoses in the garage, then at least it’s in the same house. Naloxone is not the treatment for the opioid epidemic. But we can’t get someone who is dead into treatment.
I have no illusions that simply making naloxone available is going to turn the tide, but it certainly is an important part of it.
Dr. Anderson: From your unique viewpoint, how much progress do you see in relation to the opioid epidemic? Do you think we’re approaching an inflection point, or do you think there’s a long way to go before this starts to turnaround?
Dr. Adams: When I talk about the opioid epidemic, I have two angles. Number one, I want to raise awareness about the opioid epidemic—the severity of it, and how everyone can lean into it in their own way. Whether it’s community citizens, providers, law enforcement, the business community, whomever. But in addition to raising awareness, I want to instill hope.
I was in Huntington, West Virginia, just a few weeks ago at the epicenter of the opioid epidemic. They’ve been able to turn their opioid overdose rates around by providing peer recovery coaches to individuals and making sure naloxone is available throughout the community. You save the life and then you connect them to care. We know that the folks who are at highest risk for overdose deaths are the ones that just overdosed. They come out of the ER where we’ve watched them for a few hours and then we send them right back out into the arms of the drug dealer to do exactly what we know they will do medically because we’ve thrown them into withdrawal and they try to get their next fix. If we can partner with law enforcement, then we can turn our opioid overdose rates around.
A story of recovery that I want to share with you is about a guy named Jonathan, who I met when I was in Rhode Island. Jonathan overdosed, but his roommate had access to naloxone, which he administered. Jonathan was taken to the ER and then connected with a peer recovery coach. He is now in recovery and has actually become a peer recovery coach himself. Saving this one life will now enable us to save many more.
Yet we still prescribe over 80 percent of the world’s opioids to less than five percent of the world’s population. So, we still have an over-prescribing epidemic, but we’ve surpassed the inflection point there. Prescribing is coming down.
But another part of this epidemic was that we squeezed the balloon in one place and as prescribing opioids went down, lots of people switched over to heroin. That’s when we really first started to see overdose rates go up. Well, it’s important for folks to know that through law enforcement, through partnerships with the public health community, through an increase in syringe service programs, and through other touch points, heroin use is now going down in most places. Unfortunately, now we’re seeing the third wave of the epidemic, and that’s fentanyl and carfentanil.
Dr. Adams is the 20th Surgeon General of the United States, a post created in 1871. He holds degrees in both biochemistry and psychology from the University of Maryland. In addition, the Surgeon General has a master’s degree in public health from the University of California at Berkeley, and a medical degree from the Indiana University School of Medicine. Dr. Adams is a board-certified anesthesiologist and associate clinical professor of anesthesia at the University of Indiana. He has been active in a number of national medical organizations, including the American Society of Anesthesiologists and the American Medical Association.