The surgeon general and his brother: A family’s painful reckoning with addiction

MECHANICSVILLE, Md. — The path that Dr. Jerome Adams took to the office of U.S. surgeon general begins in this southern Maryland town, where crab restaurants dot the rural landscape, where signs warn drivers to watch out for Amish horse-drawn buggies, and where he grew up on a rolling road with three siblings, including a brother five years his junior. Phillip.

But as Jerome’s career has taken flight — he’s won scholarships for college and medical school, taken charge of a state health department, and ascended to become “the nation’s doctor,” as his job is nicknamed — Phillip’s has been diverted.

For two decades, the younger Adams has struggled with substance use disorders, the consequence of an untreated mental health issue, his family believes. With his addiction unaddressed, he has cycled in and out of incarceration for years — a living emblem of the intractability and reach of the public health crisis confronting his brother.

“One of the most frustrating things is being surgeon general of the United States and feeling like you can’t help your own brother,” Jerome Adams said last month in his Washington office, in his first extensive interview about his brother.

About 25 miles away from Jerome’s office, Phillip is serving a burglary sentence in a state prison in Jessup, Md.

“My substance abuse has been the key factor for my history of incarcerations and I’m very tired of the road I have been on with my drug use,” Phillip, 38, wrote last month in a letter to STAT.

Jerome, who was sworn in in September, has watched as addiction has not only ransacked his brother’s life, but wrested their whole family. His sister, while in college, had money she had saved from a waitressing job stolen from inside her pillowcase. His mom has called Jerome crying, at a loss for how to help Phillip.

If Phillip’s case has given Jerome a personal connection to the addiction crisis, one that links him to the millions of Americans who share the same worries about loved ones, it has also provided him with a clear demonstration of the barriers to recovery. Jerome Adams, whom Vice President Mike Pence has said “has an extraordinary gift for empathy,” has seen his brother repeatedly fight — and then fail — to get treatment and been left to “go back down the same pathway over and over again.”

Adams assumed his new post as the country rethinks how it views addiction, reframing it as a public health issue that demands an expansion of treatment instead of a reliance on incarceration.

It’s a movement that is progressing haltingly and unevenly. But even if it somehow shifts the public’s understanding of addiction, what happens to the scores of people — particularly people of color like Phillip Adams — for whom that shift might have arrived too late, whose drug use the government decided deserved punishment?

“Bluntly, in so many ways, I’m being told/it’s being said its better for me to just sit in the back of the jail and not work or get treatment, knowing I need it and meet the qualifications for it,” Phillip wrote to a judge in one of dozens of letters contained in court documents reviewed by STAT. “Please see me as a person, same as you and not a file number.”

That letter was written in February 2009. Almost nine years later, Phillip Adams is still sending letters to judges from behind bars, asking to get treatment.

When Jerome Adams was in high school, with a thin mustache, he was a standout student: the honor roll, the track team, and on. Growing up, Phillip pursued his own interests. He could draw and sing and compose poetry.

But when he arrived in high school, Phillip started showing signs of what his family believes was depression. Jerome and Phillip’s sister, LaToya Adams, said it was clear in photos from that time: Phillip stopped smiling as he transitioned from middle to high school. (The Adams siblings have another brother, Richard.)

Their mother, Edrena, recognized the change in Phillip right away, said LaToya, who is a few years younger than Phillip. Edrena tried to find a counselor who could help Phillip, but nothing stuck.

Like some of his classmates, Phillip began experimenting with drugs and alcohol. One night, he told LaToya that he had been given a Vicodin at a party.

Drugs became a way for him to cope, LaToya said: when he wouldn’t do well in sports or in school, or just wanted to feel better. He began taking Percocet regularly. He spiraled, falling into trouble and getting suspended for fighting. He was shuttled to various high schools before landing in a juvenile detention facility in Baltimore, where he earned his GED.

Phillip then came home for a few years. The problems persisted.

His first run-in with the law as an adult came in 2002, when he was arrested for marijuana possession, court records show. A few years later, he was arrested for selling crack cocaine at a gas station a few miles from his family’s home. He pleaded guilty in March 2006 and was sentenced to 18 months in the county jail.

That month, he started writing to the judge in his case, asking to be put on probation. He vowed that “the last thing I would ever do in this world is something to violate that probation and put me back here.” He described his family: his parents, who were teachers; his sister, who was getting a master’s degree; and his brother, the doctor.

“I’m just simply stating that I do come from a pretty good family,” he wrote. “All familys have there problems but in mine, its just been me lately and I feel its long overdue that I get myself together.”

Each time Phillip was released from jail, his family was ready to help. They knew the challenges that awaited him. So their father, Richard, would try to connect him with a job and a car and help him renew his driver’s license, LaToya said. They would allow him to live at home.

For a while, things would seem promising. Phillip would be the caring person his family knew he was at his core. He would check in with Edrena to make sure she had taken her medication. He tried to take in dogs that needed a home.

But time and again, Phillip would stumble. In the letter to STAT, Phillip wrote that he “experimented with just about every drug there is to do.”

“I’ve watched my brother over and over and over again come out of incarceration with the best of intentions, determined that this is the time things are going to be different,” Jerome said. “And then he goes back to a neighborhood where the people who were selling him the drugs are still around and the bad elements are still around, and he can’t get a job, or he gets a job that’s paying minimum wage and he can’t even afford the transportation back and forth to the job, and ultimately he ends up in a situation where he throws his hands up and says, ‘Why am I even trying?’”

At times, Phillip didn’t show up for scheduled court appearances. He couldn’t or didn’t provide his probation officer with proof he was working or enrolled in a treatment program. He stole from his family, lifting checks from his parents and cashing them. He kept getting arrested, not just for drugs, but also for theft, money forgery, and burglary.

With his record of violations, judges sometimes scoffed at Phillip’s requests for leniency. At a hearing last year, a judge wouldn’t grant him bond because he had failed to come to court so many times. “A flight risk,” the judge called him.

STAT outlined Phillip’s story to a half-dozen experts and advocates. While they said it was difficult to draw conclusions about one person’s case, they described issues at the intersection of addiction and criminal justice that his case seemed to reflect, including the cyclicality of incarceration and lack of treatment options.

“Marching down the jail-prison path can set people up for lifelong failure,” said Michael Botticelli, who led the Office of National Drug Control Policy during the Obama administration and is now the executive director of the Grayken Center for Addiction at Boston Medical Center.

Recidivism is common because former inmates have such limited options once released, the experts said. The risk is only compounded when they have untreated substance use disorders.

“We take people with a health problem and we throw them in a place where they’re not receiving evidence-based help, then those folks are released into the community with little support and no linkage to programs,” said Leo Beletsky, an associate professor of law and health sciences at Northeastern University.

Phillip relied on a series of public defenders over the years. In court filings, they argued that his substance use disorder was the underlying reason for his crimes. Phillip himself attributed his mistakes to drug use.

When he once found out he had been cited for a parole violation, “I really lost it and the drugs took over,” he explained to a judge in December 2008. The next month, he wrote that his “FTAs” — or failures to appear in court — “all came in a close time period where I was very heavy in drug use and confused with what to do.”

There are consistent themes in Phillip’s letters. He tries to justify his slipups, he vows to do better, and he appeals to the judge to give him another chance. But one distinct shift occurs after a few years: He recognizes that he has a disorder.

In October 2006, after he was sent to jail for the first time, he told a court he wanted to join a drug treatment program “not because I felt I needed it, but to show my willingness to comply and progress while I’m here.”

By 2009, his attitude had changed. The day after he was evaluated for a treatment program, he noted for the court that he had finished reading the handbook. He highlighted that he was attending Narcotics Anonymous meetings and counseling in jail.

“I know who I am and I know my life deserves better than what I’ve given it,” he wrote.

The quality of treatment programs for inmates varies widely, experts say. Still, for many people, incarceration provides an introduction to such programs, in part because addiction awareness and treatment remains so limited generally.

But even as the court system presented treatment opportunities for Phillip, it also threw up barriers that prevented or delayed him from starting them.

Phillip wasn’t let into a drug court — which can mandate treatment instead of incarceration — because he had been convicted of distributing drugs, not just possession. (People who sell drugs often do so to support their own addictions, the experts said.)

“I’m not going to lie to you mam, I feel like I was just smacked in the face,” Phillip wrote to the judge after he learned about the decision.

In 2009, Phillip completed an addiction assessment, and the counselor who conducted it determined that he qualified for a 28-day residential program. At first, though, he wasn’t allowed to go because of a pending court date, records show. By the time that was cleared up, the spot in the program had been filled, delaying his entry into the program by a few months.

In 2011, Phillip was cleared to start a treatment program by one court system, but a hangup with his probation in another court system prevented him from enrolling, according to a motion filed by his attorney asking the judge to close the latter case.

In other words, he couldn’t get treatment unless the judge said so.

Jerome mostly experienced Phillip’s addiction from a distance. He was in college when Phillip started high school, and he went to medical school and built his career in Indiana, eventually becoming the state’s health commissioner. Phillip only got in touch when he needed something, money or help out of a jam. It strained the brothers’ relationship.

“In hindsight, I could have and should have been a little bit more sympathetic and understood that he had a chronic disease,” Jerome said.

The family would sometimes call the authorities when Phillip stole from them, and then they would go to court to ask for treatment on his behalf. The situation bred a sense of helplessness and self-doubt for his parents, Jerome said: They called the authorities in hopes of steering Phillip into treatment, but doing so jeopardized his freedom. Did that make them bad parents? (The Adams parents declined to talk with STAT for this story.)

The family has strived to accept that Phillip’s actions are symptoms of his addiction, not a reflection of his character. LaToya, who is a counselor who has worked on mental health and substance use issues and in the criminal justice system, has gone to therapy herself to sort out that distinction.

“It’s frustrating as his sister, but it’s also frustrating as a professional,” LaToya said. “I feel like I’m helping other people, so it makes you question yourself. Like, why can’t I help my own brother?”

Phillip has sought out treatment when he’s been out of jail, sometimes after being ordered to do so by his probation officer. But there were few options in the area, LaToya said, and the family struggled to find one that worked for Phillip. The programs were also expensive; Jerome has helped pay for them.

The family still has plenty of questions about Phillip’s addiction. Not least of all is this: How did Phillip wind up where he is while Jerome is where he is?

“I ponder that all the time,” LaToya said.

The answer speaks to the pervasiveness of addiction. But for Phillip’s family, that has done little to obviate the regret they feel.

LaToya said her mom still blames herself for not pushing harder to help Phillip in high school. Jerome was close with their father growing up — people called him “Little Ricky,” he said — but his brother never had as tight of a relationship with him, so he wonders if having that role model made a difference. Did Phillip have a genetic predisposition to addiction and, if so, what does that mean for Jerome’s three children?

Jerome raised the notion that his successes might have exacerbated Phillip’s feelings of inadequacy. “Phillip has always compared himself to Jerome,” LaToya said.

There are no easy answers, but these are things the family is left to think about.

Phillip’s story hovers over how Jerome Adams envisions improving the national response to the addiction crisis. A key problem, he believes, is that people sort themselves into two factions: those who approach addiction from a “public health, chronic disease mindset” and those who hold a “law and order, moral failing mindset.”

The position of surgeon general does not come with great policymaking powers, but it does come with a megaphone that Adams can deploy to get the two groups to start working together.

At a recent panel discussion about the opioid epidemic hosted by the National Academy of Medicine, a judge joked that it was odd for him to be sharing a stage with health officials. Adams jumped on the remark.

“The No. 1 touch point for people with addiction is not a physician … it isn’t a medical touch point. It is the law enforcement community,” he said.

He added: “This room should be half full from the law enforcement community if we really want to tackle this issue.”

That’s a matter both practical and personal for Adams. Through his brother, he has seen what happens when addiction care is left to the criminal justice system.

“It just doesn’t make sense to not engage law enforcement in particular if you want to change the way people are treated right now,” Adams, who had two state attorneys general at his swearing in, said in the interview.

Adams has impressed public health experts of all stripes with his work. In Indiana, he famously helped convince then-Gov. Mike Pence to open a needle exchange to stem a historic HIV outbreak. But he is also serving in an administration that at times has emphasized a robust law enforcement response to drug use and has sought to roll back health coverage.

When he spoke about addiction this summer, President Trump lamented the decline in federal drug prosecutions under the Obama administration but didn’t mention treatment. Attorney General Jeff Sessions has equated a softer response to drug crimes with an increase in violent crime.

Jerome Adams insisted that the Trump administration understands that combating addiction requires a bolstered public health effort. He noted that Trump has spoken about his brother’s alcoholism and that the president’s opioid commission made several recommendations that could expand treatment.

This more compassionate approach to drug use has been driven in part by the changing demographics of those affected, as addiction has become a reality for more suburban white families. Experts say they appreciate the shift but are dismayed that drug use was not considered a health issue when it was seen as a scourge perpetuated by and limited to communities of color.

When asked if race played a role in the justice system’s treatment of Phillip, Jerome Adams did not answer directly. Instead, he focused his answer on how the perception of addiction is changing.

“I think we have a real opportunity here,” Jerome said. “I’m not at all upset about what happened in the past, I’m more encouraged by the fact that now folks are saying we need to treat this as a public health problem.”

When drug users like Phillip are arrested, Jerome said, they should be given a choice: get treatment or go to jail. He said he understood that law enforcement agencies are often underfunded and overworked, but that getting certain people into treatment instead of incarcerating them could save a lot of the hurt that comes with substance use disorders going untended.

“We can’t ignore the fact that there are crimes being committed,” Jerome said. “I’m not saying my brother or anyone else should be absolved of all the crimes and the real harm they’ve done to people. I’m saying the way that you prevent that from continuing to occur is by making sure those folks have access to treatment, so that when they do get out, they don’t go down the same pathway.”

Getting people into treatment can come with false starts. Many do not follow up with programs, and those who start on their recoveries sometimes return to drugs, which can trigger legal consequences if they are in court-mandated programs. Experts say, though, that instead of kicking people out, treatment programs should accept that some patients use drugs on their path to recovery.

“Relapse is a genuine part of the disease process,” said Dr. Ayana Jordan, an addiction psychiatrist at Yale. “It should be expected.”

One benefit of his new job, Jerome said, is meeting people who have been in similar situations as his brother and recovered. It’s shown him that his brother is not lost.

And he knows that his family has not suffered the worst consequence of addiction.

“My brother is at least alive,” he said.

This is Phillip’s second stint in state prison. He previously served a two-year sentence for theft, forgery, and credit card fraud, records show. Then, in February of this year, he pleaded guilty to a burglary charge, after breaking into a bar and pilfering about $250. He was sentenced to 10 years.

Phillip has told LaToya that he thinks 99 percent of his crimes are related to substance use. He is still writing to the judge asking to get into a treatment program, and in his letter to STAT, he said he hasn’t given up because “although I made my mistakes, true … my bad choices, true … and so forth … I desire to be better and I want to do what will help me to further progress.”

Phillip also recalled his brother’s success beginning as a student — “I remember very clearly him staying focused in his books more than anything else” — and on from there.

“I couldn’t be more proud of him. He’s a good guy, a great father and the best brother. For what he has made of his life? I can only admire and respect it,” Phillip wrote.

“Knowing how he was as a younger kid, its not hard to see how he can be where he is at now,” he continued. “He stayed on the right path and has been blessed for it. I myself? Well I strayed quite a bit and that’s pretty much why he went his direction and I went mine.”

Surgeons general serve four-year terms, sometimes rolling from one administration to the next. If he completes his term, Jerome Adams will leave his post in 2021.

Phillip’s current release date is in 2023.