The Surgeon General comes to Nashville

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ehrenfeld with surgeon general for web.jpg

The doctor appeared in uniform. It took all my effort not to snap to attention. I will always be an Army brat…

“Thank you so much for coming. I am so proud to be in here today wearing this uniform. I grew up in a family and in a part of the country were people served. I didn’t have an opportunity to do so because of health issues and I’ve been waiting over 25 years to be in uniform.”

Vice Admiral Jerome Adams, M.D., the twentieth Surgeon General of the United States, had just talked about the importance of the United States Public Health Service and recognized from the stage of Vanderbilt University’s Langford Auditorium three members of it’s Commissioned Corps in the audience last Friday. The Corps has been around since the late 18th century and wears a uniform that reflects its Navy background.

Dr. Adams began his talk about opioid addiction in America through a personal reflection.

“I’m a dad, and I will tell you…you put two young boys together and the stupidity factor goes up exponentially!” Adams said to shrieks of audience laughter. “One of the favorite things for my wife and I to do is to turn on the intercom in our house…we have an intercom system…and listen to our boys plot and scheme. They have had some incredibly stupid and some incredibly ingenious ideas on occasion.”

“I also have an 8 year old little girl who is far more mature than both the boys put together…” Adams followed to more laughter.

“My kids are really important to me, not just personally but also professionally,” Adams continued.

“For the second year in a row life expectancy in the United States has gone down. I represent for the first time in fifty years a generation of parents who will have to look their kids in the eyes and tell them that they are likely not to outlive me. That is not a future I want for my kids or any other kids in this great country of ours. It makes me want to be a more effective Health policy advocate, and so it should for you too.”

The audience was mostly composed of physicians and medical personnel who came to hear Dr. Adams remarks as part of the Vanderbilt University School of Medicine’s Department of Health Policy “Grand Rounds” programme.

“I want to tell you a quick story about Scott County Indiana to help you understand where I’m coming from as far as my priorities as a Surgeon General,” Adams continued. Prior to becoming the Surgeon General, Dr. Adams was the Indiana State Health Commissioner and coordinated the response to a major outbreak of HIV infection that resulted from injectable drug use.

“Past surgeon general’s have picked a risk factors such as smoking or obesity…or picked a disease to attack. I think for them, that was very appropriate. There were, and are, still major gaps and risk factors that still exist for diseases that we need to address in this country,” Adams said.

However, being in public health since 2000, there is something I have noticed…I have noticed that communities that have the highest diabetes rates also have the highest smoking rates, also are the hardest hit by the opioid epidemic, also have the highest infant mortality rates and the highest stroke rates, and the highest everything else…

So, for me…I could have picked a disease, but I’m tired of playing whack-a-mole. I’m tired of watching this move from one place to another place. I want to get as far upstream on this issue as much as we can.

He tells the audience a story about a man who sees someone drowning in a stream and how this person instinctively jumped in and rescued him. Then saw another and did it again…and again…and again. After saving thirty people, he gets out and begins walking away. The crowd that gathers asks him where he is going? “Upstream,” he replies. “Because I want to see where all those people are falling in and go fix that. I’m tired of swimming…”

“That’s what we need to do as public health advocates,” Adams said.  “We need to figure out how to get upstream. For me, it all comes down to better health and better partnerships.”

Here is another shocking statement I often make to folks,” Adams continued.

Public health is easy… don’t smoke, eat better, exercise more…anybody here do not know any of that? The problem is we’re just absolutely terrible at motivating people to actually do any of this? I am all in favor of scientific advancements…The problem is it doesn’t matter if we can come up with the next great treatment or the next great research finding…we just can’t get people to do the things that we know will work. That comes back to us being better communicators…(We will get) better health through better partnerships.

Dr. Adams then told the story about the HIV outbreak he had to manage. He told the story of a town in Southern Indiana that developed a high infection rate of HIV and required a thoughtful response.

(Scott County, Indiana) is just above Louisville. Like a lot of rural areas…it was mostly white with a very high high school dropout rate. A lot of manufacturing jobs had left…but also one of the last places on the face of this Earth that you would expect to have an HIV outbreak. In over two years (when he got there) this town of four thousand people had over 230 cases of HIV. This was a rate of infection that was higher percentage-wise than in southern Africa, and that was while I was the State Health commissioner…so I had to deal with it.

What does the science say? The science is clear…to stop the spread of HIV through injection drug use you need a syringe service program. But syringe service programmes are illegal in Indiana. Now there were a lot of health policy advocates…perhaps some of you in the crowd would agree…that said “Dr. Adams, you should use your emergency authority to go open up a syringe service program, because that is what the science says to do.”  There was a New England Journal of Medicine article that talked about how I did everything wrong here, and I should have led with the science.

Here is my answer to all that: If I had gone in there and open up a syringe service program with my authority, the local police would have set up shop just outside my view and would have arrested the first two or three people who came in, and no one else would have came in again. Instead of 230 cases of HIV, it would have become 500 to 600 cases of HIV pretty soon after.

The reality is science is one part of a very complicated public policy equation. The key word in public policy is “public”…and we have to implement these policies in a way that not just emphasizes science but takes into account sensitivities and local culture…

I looked around me and saw more than one white-coated fellow shaking their head. Dr. Adams continued…

I didn’t pick up a telephone and yell at somebody that I am the big bad Health Commissioner and this is how I need to fix your problem. I drove to their community and had a beer and a sandwich with the local Sheriff and asked him what were his concerns?

(The audience had a hearty chuckle at that.)

Why did I do that? Because the Sheriff is someone (local leaders) listen to when you need to implement policy.

The Sheriff said that he was concerned that his officers were going to get stuck with needles if that sort of programme was ever implemented. He was concerned about the revolving door to his jail, about all the calls they were getting by citizens to pick up dirty needles on the streets…

I said “you know…I completely understand what you talking about and those are valid concerns.” I listened…and I validated his concerns. And then I said “you know, if we do this syringe service programme right…we can get the revolving-door business to stop and lower the rate of officers being stuck by needles by sixty percent. And we will bring in as many if not more dirty needles off the streets then are going out there.”

The Sheriff then replied “You know Dr. Adams? I have real concerns about this, and I still do…but if you’re willing to work with me then I’m willing to work with you.” He then went to the governor…who is now our vice president,…as a conservative Sheriff (and a former Navy SEAL) and told him that this was the right thing to do. We were able to get our syringe service program implemented and get public support…and the rest is history.

“We have to learn to be better partners,” Dr. Adams finishes.  “Because the truth is people don’t care what you know until they know that you care. We have done a bad job as public policy and public health advocates of showing people that we care about what is important to them.”

The Surgeon General sits down and a moderator comes on stage to ask questions.

First question: Tell us about a life experience set you on your path?

Dr. Adams says that he never thought that he would be a doctor growing up because he had severe asthma. He still has asthma today and pointed to the pocket where he keeps his inhaler. He said that he wanted to go to the Naval Academy but couldn’t because of his asthma. He was in and out of the hospital and Clinics over and over again and he had never met an African-American doctor until he went to college.

“I was a really smart kid…but I didn’t have anybody who look like me that I can relate to to make me feel like that this would have been a career path that would be an option for me. That opened the door for me to think about going down this pathway… it showed me the importance of diversity and inclusion and making sure we have women present, minorities present and that we have folks that other people can relate to because it means so much just to know that there is someone like real people present at the table. It’s very important to think about diversity and everything we do in public policy…because it makes us more effective advocates.”

Adams then talked about using different ways of communicating health policy to get a response. He recently used the NCAA Basketball Tournament, an opportunity to talk smack with a rival physician on Facebook, as a way of subtly mixing important health messages alongside what folks are really talking about.

As a trauma anesthesiologist by training, he thinks his practical experience translates well to being a public health advocate. “Saving lives is a big high for people who work in emergency medicine,” Adams admits. But there is a down side…

“I see the same people over and over again. What was the point of saving that person’s life just so they could go out and get shot again? What is the point of saving that baby’s life if I am going to send them back to a home environment? It’s critically important that we have highly trained people to take care of individuals when they need it…but at the same time, we’re just fishing people out of the stream on the back end. I got a degree in public health because I want to talk to people who need help…and stop so many people from jumping into that stream on the front end and help them…so I can get off that hamster wheel.”

 

In Tennessee, more people die of drug overdoses than traffic accidents. How do you use your background to help people understand the scope of this epidemic?

“There is a person dying every 12.5 minutes from a drug overdose,” Adams begins. “Over 2.1 million people suffer from a substance abuse disorder. It is a scourge that is touching every single community.”

Dr. Adams pauses.

“My own brother is in state prison right now after stealing money to support his own addiction and the judge gave him a ten year prison sentence.”

And the room goes deathly quiet…

“Yeah, the Surgeon General’s brother who grew up in the same house, in the same family…is sitting in state prison while I’m talking to you here on this stage…

I tell this story because stigma kills more than any other risk factor out there. Stigma kills more people than smoking. Stigma kills more than obesity. Stigma kills more people than drugs. The only way we’re going to lower stigma is by helping folks see addiction for what it is…a chronic disease. The way to do that is by telling stories, by helping folks see that addiction isn’t always just someone shooting up drugs in a back alley. It’s the mom who had that (emergency) C-section, who was over-prescribed (addictive drugs), who a year later is addicted to heroin because they cut off the pills that she became addicted to.

I have heard that story! It’s the high school quarterback, or the prom queen…who had a sports injury and was given vicodin instead of (over the counter medicines) or ice and elevation…and is now addicted to opioids….

It’s Rachel, whom I just met yesterday…beautiful and looks like your typical Southern Belle…she was hanging out with her boyfriend while drinking, and her heroin-using boyfriend talked her into trying heroin while she was in an intoxicated state…and she said it was just like a light switch. She spent the next several years trying to kick the habit. She’s now in recovery, but these are the faces of addiction.

We need to help folks see that the diseases that we care passionately about…the people that we care passionately about…it’s not them, it’s all of us. Because what is stigma? Stigma is when you take a group of people and separate them into “us”…we’re the good people – we’re doing the right things…and “them”…they’re bad people who deserve all the bad things that are happening to them.

The white-coated audience is now leaning forward and listening hard. He continues:

“The one opportunity that exists in this opioid epidemic is that folks are seeing that there is no more “us” and no more “them”. It’s all of us…and we all have a tremendous opportunity to use that to bring partners together (to fight this.) If I had asked two or three years ago a police officer, a faith leader, a CEO of a large company…to all come into a room together to talk about a health issue…there’s no way all of them would have shown up. But now everywhere I go, folks are coming together to talk about the opioid epidemic. We need to use this opportunity to create better partnerships and then use those partnerships to figure out what comes next…

 

Dr. Adams is asked about his recent advisory concerning Naloxone and why he issued it. (Naloxone, better known as Narcan, is an over-the-counter drug used to treat the effects of opioid overdose. The advisory requests Americans to have this drug on hand in case of an overdose emergency.)

He explained that this was the first Surgeon General’s advisory in thirteen years, and that this type of message is reserved for moments when there is a problem that is touching everyone and there is a need for a universal call to action. The last one was concerning drinking during pregnancy.

“We have an opioid epidemic, but what makes it an epidemic?” he begins.

“An epidemic is when something goes above the baseline. It’s not because people are misusing substances…people have been doing that since time began…it’s an epidemic because people are dying at an unprecedented rate. But here is a more shocking statistic: 77% of overdoses are occuring in a non-medical setting and 56% are occuring at home.

I’m tired of meeting mothers and fathers whose children have died just in the garage, just in the bedroom…just on the other side of the door knowing they could have potentially intervened if they had known about and possessed Naloxone.

It takes about four minutes to get a (drug overdose induced) brain injury. Has anybody ever seen a called ambulance show up in four minutes? I haven’t…we are not going to dig ourselves out of this hole by just relying upon 911 and first responders…we need everyone to see that they can be a first responder. To use that opportunity to save a life…to connect people to treatment and recovery.”

He followed with what most in the audience would consider a surprise.

“I have a call to action for all of you. The next time you go to the pharmacy…I want you ask for Naloxone. It’s important that you do that…because only by doing that can we lower stigma. If we just have people who need Naloxone coming into the pharmacy and asking for it…they’re going to get the eye rolls, judgement…and they are going to walk away without getting it at all.

Only by asking are we going to make sure that it is stocked on the shelves. Only by asking are we going to find out the reality of how much this costs for consumers…

I issued this advisory to turn the tide on this epidemic…to save lives, and to create an opportunity for each one of you have a discussion about an issue. We’ve talked about communication…you now can say ‘The Surgeon General of the United States issued the first advisory in thirteen years…we need to have a discussion about this topic’ and lean into prevention, treatment, recovery…if that’s where you want to go with it. Because we know four out of five heroin users get started with a prescription opioid. It’s an opportunity to have a conversation, and save a life.”

 

What about the cost of Naloxone? How do we get this into as many hands as possible?

Dr. Adams says that as someone as politically agnostic as they come, his superiors have some ideas in mind that are as bold as they come about drug prices. It is a problem…and all options are on the table.

Adams is encouraging states and municipalities to look at bulk purchasing agreements, combining funding streams and more to make Naloxone affordable. He says that the real problem is that makers of Naloxone are small companies and do not have the flexibility toward pricing and manufacturing that large companies have.

“If we can drive up demand, then they can see that they can make money at lower price levels,” Adams says. He is committed as the Surgeon General to making sure that no one has price as a barrier to possessing Naloxone.

“We have worked with these companies on patient assistance programmes,” he continues. “The truth is that ninety-plus percent of people can get Naloxone for a price lower than an insurance copay. We want to make sure that the ten percent who need it most are able to.”

We shifted over to the audience question segment. This was a skeptical, but friendly audience of medical professionals who were personally invited by Dr. Adams to take their opportunity to stump the Surgeon General…

What is your opinion about alternative forms of care, asked a nurse?

“We know that healthcare only fixes ten percent of someone’s problems. Environment and behaviour is responsible for the other ninety percent, according to Dr. Adams.

For example diabetes…we can come up with the best drug in the world to treat diabetes but that’s fishing people out of the stream again. What we really need are communities that are walkable and for residents to get more exercise…we need more fresh fruits and vegetables available to help people not go down the diabetes pathway.

We also need to talk to each other….we need better health and better partnerships. I was shocked (as Indiana health commissioner) that the people at the state health department did not know the people at the hospital…we have got to talk to each other…we have got to pay for outcomes instead of paying for procedures and pills.

Dr. Adams then swung back into his original point.

Many people feel like they can wait until they fall into the river and then they can get a pill that’s going to be a quick fix. There is plenty of blame to go around for the opioid epidemic and all of these other diseases, but I think we have to change the mindset of the community and help them understand that it is about (prevention) and not about taking care of the individual after they get sick. Yes, we need to take care of folks when they get sick…but too darn many people are unnecessarily getting sick with preventable diseases and illnesses.

In response to a question about overdose-related deaths, Dr. Adams says that the vast majority of overdose-related deaths are due to injection form…mainly because the injectable stuff is far more powerful.

“That’s why the Naloxone advisory was so important,” he followed.

But we can’t ignore the fact that we are still prescribing ninety percent of the world’s Vicodin to five percent of the world’s population…and Tennessee is prescribing at a higher rate than the national rate. Overprescribing is still a major problem…we need to make sure the clinical practices reflect the (CDC guidelines) so we are not putting people at risk whether they are injecting or taking pills.

He segueded into a follow-on question about addiction.

Based on folks that I have talked to, and my own experience with my brother, unfortunately there are people out there that with their first taste of an opioid…it’s like a light switch. It is that powerful…(it is that easy) to become dependent on.

Dependence is different from addiction. We know that people can become addicted to a substance almost immediately. Dependency is a more physiologic state…that comes with repeated usage. We often judge folks who become addicted…we need to understand that addiction is different for every person. Evidence-based treatment has to be individualized accordingly.

An African-American medical resident took the opportunity to ask an important question. Is the opioid epidemic getting more attention now because it has started to affect the white suburbs?

“I get that question a lot,” he began. “How come you all care more about the opioid epidemic now because there are white people dying from it?”

Here’s my answer every single time. There are folks who spend their entire lives trying to get people to pay attention to the scourge that is opioids. If we’re going to get real about this subject…it is a little bit disingenuous to say now that people are engaged, for whatever reason, that happened, but now we have got an opportunity.

What I am focused on, instead of looking backwards and applying blame, is trying to make sure that policy and funding that comes out (in response) to the opioid epidemic is applied in an equitable way to lift up all communities. What I want to make sure is that the funding does not all go to to rural white America and skips over communities of colour and communities in need. (If that happens) we’re just going to continue this vicious cycle.

Dr. Adams talked about how he got the Indiana legislature to contribute an extra thirteen million dollars to combat infant mortality rates in his state, the overwhelming majority of deaths being of children from a minority background.

If I go into most of the counties in Indiana that are 99% white, they would not know of an African-American baby that had died. They would not know of a Hispanic baby that had died…but they do know that there are potholes in the street that need to be filled. They do know that the police department needs new cruisers. They do know that they need new jobs in town and they would rather see that money go toward recruiting jobs to their town because that’s what their day to day life looks like…

So what did I tell these white communities? Your infant mortality rate is much higher than in the urban communities and other places in the state. I showed them how they fit under the disparity tent and how inequities affected them…and that allowed us to have a broader conversation. If we’re going to be honest, all of us are primarily interested in taking care of ourselves. So we have to show folks how caring about and addressing disparities affects them and their daily lives.

He then focused upon medical practices.

We now know that a lot of cultural legacies and disparities in our country affect trust and people’s willingness to be compliant and to interact with the healthcare system. So, if you want to get paid…you had better look at the legacy of disparities playing out in your communities. You had better make sure that you have culturally sensitive and appropriate training for everyone who works within your hospital system. You have to show people why it matters to them instead of expecting them (to automatically understand). Their top five needs is not always your top five. Show everyone how they will benefit, and then we will all be much more successful.”

Dr. Adams was asked if he felt the funding recently allocated in the Federal Budget for fighting the epidemic was adequate?

“President Trump has asked for and received more money from Congress than ever before allocated towards the opioid epidemic,” he replied.

In any financial discussion, there is a limited pie and at some point, we have to make a case to the taxpayers that it’s worth paying for this and not paying for “that”…or we have to raise taxes. Right now, we are at a state in this country where people are not inclined to raise taxes, so we have got to figure out how to do more with what we’ve got…and I’m convinced that we can do that.

He says that the problem is that multiple agencies have individual response plans to deal with this epidemic. What they needed was a joint response plan.

We have got to find a way to blend these funding streams to bring folks together so we’re not developing three separate plans. We need one comprehensive plan (that will be cost-effective in doing so) and make it twice as effective. That is critically important.

Dr. Adams then touched upon a controversial subject: the argument that outpatient care should be considered over inpatient care for most who are dealing with addiction. The Surgeon General used an economic argument.

We are not going to be able to spend our way out of this problem…because if we look at the numbers we will never be able to, or willing as a country to throw all the money at this thing that folks are saying we need. We need to rethink the way we deliver care. Everyone is not going to be able to get intensive inpatient six-month treatment (in addiction treatment centres). It’s just mathematically not going to work. We need to look at models that emphasize outpatient treatment, at alternative care models…and then only for the people who most need it choose inpatient treatment. We need to rethink the way that we are going at this.

We’re going to have to engage new partners…we need (to engage businesses) in the fight and get them to throw some money into the pot. The more we can bring these other partners in and combine our funding streams and work smarter, in addition to working harder, the more effective our response will be. We are just not going to be able to spend our way out of this problem with Federal money.

The Surgeon General was asked about IMD (Institute for Mental Disease) exclusions. Many places do not have access to inpatient care as a result of laws capping the number of beds in current facilities and restricting the opening of new facilities. What was he planning to do about this?

Dr. Adams began with an explanation of why the current laws came about. He says that there was a concern years ago that people (with treatable conditions) were just getting institutionalized and being locked away. Medical professionals came to realize that this was a totally wrong approach and laws were passed to prevent this from happening. That is why there are rules capping the number of beds that inpatient care facilities can have today…they did not want to incentivize this type of treatment. Fast forward to today, and these rules limit anyone who wants to open up a new treatment centre or expand beds at present centres.

Dr. Adams said that he recognizes that the rule needs to change, but right now they do not have the authority to make that happen. Only Congress has the authority to make this change, but what they could do now is offer waivers to the exclusion law. Every state that has applied for the waiver had received one, according to the Surgeon General…and they want to approve more.

But he reminded the audience that they were not going to solve the problem by utilizing a totally inpatient bed approach. Inpatient treatment is a part of the fix…”but in my opinion a small part,” according to Dr. Adams.

“We need to increase outpatient treatment which studies show actually are more effective than inpatient treatment,” Adams said. “Some people do better with intense inpatient treatment, but for more folks it’s better to have them in an outpatient home environment where they function a lot better and the begin to build up the resources in their community to be successful (in their recovery).”

The Surgeon General wrapped up with his core thoughts for the audience of physicians and medical personnel.

I have met a lot of folks in Washington who are well meaning and well intended but there is a saying there…if you are not at the table, you are on the menu. (Laughter…he admits that’s a bit dark…) If you are not at the table, then there is a lot of policy (enacted) that are not informed by the realities on the ground. It is very important that all of you are engaged in policy-making. It is very important that you are at the table helping folks to understand…(telling them) ‘Hey! That may sound like a good idea, but here’s what it looks like when you play it out in my practice and my community…’ It is also important when you develop policy that you bring different partners to the table…because you may cause unintended consequences.”

Dr. Adams used the subject of legalized cannabis as an example. He says that he gets told all the time that in states where cannabis is legal…opioid addiction goes down.

That may be so, he replies. But his friends who are health commissioners in those states see other problems happen because of it. Poisonings go up, buzzed driving becomes a huge problem…while there may be some good that comes from this, there is also just as much bad

“We’ve got to be careful and bring folks to the table…think about all this up front, and we’ve got to evaluate these programmes and decisions continually and adjust them as we move forward so we can have effective policy that helps everyone.” Adams says.

He then talked about the problem with effective pain management and rules governing the use of opiates in clinical settings as another example.

“We are overprescribing (opioids)…there’s no doubt about that,” Dr. Adams began.

But we don’t want the pendulum to swing so far in the other direction that people who need good pain management cannot get it when they absolutely need it. Unfortunately, we are getting cases of cancer patients with legitimate chronic pain who have been on opioids for a long time and getting cut off.

We’ve got to make sure these policy decisions have a net good. We want to do the most good for the most people. That starts with having everyone at the table in the beginning. It starts with having a servant heart and trying to figure out how you can serve others in addition to serving yourself…and ends with the idea of better health through better partnerships because I’m convinced that if we commit to being better partners and better communicators…better health is sure to follow.”

Dr. Adams is photographed (at right, above) with Jesse Ehrenfeld, a Professor of Anesthesiology at Vanderbilt