Expanding addiction treatment, embracing the bully pulpit: Jerome Adams on his first year as surgeon general

Earlier this month, Dr. Jerome Adams marked one year as surgeon general — a position nicknamed “America’s doctor.” In that time, he’s worked with the Trump administration as it declared the opioid epidemic a public health emergency; traveled to 26 states, Puerto Rico, and the U.S. Virgin Islands; and issued a rare advisory that has led to more Americans carrying naloxone.

On Thursday, Adams also released a report containing the latest opioid data and recommendations for what people can do to stem the addiction crisis. The initiative includes a digital postcard that Adams likened to the pamphlet about AIDS former Surgeon General C. Everett Koop mailed to every household in 1988. The postcard highlights properly storing and disposing opioid medications, other options for pain treatment beyond opioids, and treatments that exist for opioid addiction.

STAT caught up with Adams this week to see how the first year went, learn about his plans for year two, and hear his thoughts about some of the most pressing public health debates today, including safe injection sites, also known as supervised injection facilities, which a number of cities are hoping to open. Adams also updated STAT about his wife, Lacey, who is undergoing treatment for metastatic melanoma, and his brother, Phillip, who for years has struggled with addiction and is in a Maryland prison.

Adams, a trained anesthesiologist, previously served as Indiana state health commissioner, a post to which he was appointed by then-Gov. Mike Pence.

Following are excerpts of the conversation, which has been lightly edited for clarity.

What are you releasing on Thursday?

The surgeon general’s 2016 report on addiction was a groundbreaking report, but it was not something that was very accessible for the average person. What we wanted to do was to distill it down and pull out the points that are most relevant to opioids for individuals. It also reflects what the administration has done to respond to the opioid epidemic.

What I’m additionally excited about is the postcard we’re putting out. C. Everett Koop put out his letter on HIV about 30 years ago, and that had a tremendous impact on the country because it helped everyone understand that they had a role in responding to what was then an HIV epidemic. Now we have an opioid epidemic. Law enforcement can’t solve it alone. Doctors, nurses, health care workers can’t solve it alone. The postcard puts out five points that help everyone understand how they can play a role.

And we’re still talking about naloxone. One of the things I’m most proud of is our naloxone advisory. I’ve been a practicing physician for 10 years and I’ve saved a lot of lives. But I really feel like our office has saved more lives by helping to increase the availability of naloxone across the country.

How is your wife doing?

She’s doing about as well as can be expected, and I mean that in the most positive of ways. Advances in science are amazing. She’s getting immunotherapy [ipilimumab, also known by the brand name Yervoy] instead of chemotherapy. She’s fatigued, but she’s actually doing really well. She’s about to get her sixth treatment out of 12.

And how about your brother? Have you visited him or spoken with him recently?

I’m in touch with him quite a bit. They moved him from a facility about 45 minutes away to one that’s about three hours away, so it’s a lot harder to get to him. One of the frustrations is that he’s still not getting treatment. Every day I just pray that he avoids the temptations that exist. He and any other person in the prison system will tell you that drugs are still available, so what I pray for is that he can get treatment and that he can find a positive way to channel his energy and attention. We want him to come out and be a successful and contributing member of society.

What’s been the biggest change from going from leading a state health department to working in the federal government?

On a state level, I came from a state that was very red, very conservative, and I had to speak a a very specific language so that it resonated with the folks in Indiana. On a national level, I have to speak to the entire country. It is a challenge, but it is one that I really enjoy, being able to go to different states and listen to them and find out what their priorities are and what their challenges are and help them understand that the federal government is here to help everyone.

As far as health commissioner versus surgeon general, my levers are very different. I don’t have a lot of programs under me, I don’t have a lot of funding to go out there and fund different grants or programs. What I do have is the bully pulpit. Going back to the naloxone advisory, it shows you how powerful that can be when used effectively.

The House and Senate have each passed pretty substantial addiction bills and are now trying to align them. Are there certain things in those bills that you think shouldn’t be in there or things that aren’t in there that you wish were?

In general, one of the things I’m hopeful for is that there is language in the final bill that allows maximum flexibility for states and communities to be able to access funding. A lot of times Congress puts strings on grants, and I can tell you as a state health commissioner, it really restricts our ability to quickly get the funds out to people. The other thing I’m really excited about is treatment capacity. Everywhere we go, we continue to hear that there is just not enough treatment capacity. The more we can fund that and help folks understand what effective treatment looks like, the better off we’ll be.

In the past year, how many times have you spoken to or met with President Trump?

I see him or speak with him approximately quarterly. But I’m at the White House at least monthly as part of the opioid convening they have. I will be there next Friday for an opioid event. And this week I was with the second lady and Kellyanne Conway and [Labor Secretary Alexander] Acosta in Indiana [for an opioid and workforce event].

Today I visited ⁦@BeldenIND⁩ with ⁦@SecondLady⁩ ⁦@SecretaryAcosta⁩ & ⁦@KellyannePolls⁩ to learn about their innovative #PathwaysToEmployment program to help those struggling with addiction earn a livable wage #road2recovery #bhbp pic.twitter.com/y4mJJvJaxy

— U.S. Surgeon General (@Surgeon_General) September 18, 2018

To jump around a little bit, one of the things I was most excited about personally from my first year was being honored by the president and the first lady during Black History Month. That was something I will never forget — being able to give a speech to hundreds of people in the White House while my family watched as I stood next to the president and the first lady.

How have you used your relationship with Vice President Pence to elevate certain public health issues to the White House?

I wouldn’t say I’ve used that, I would say that the relationship that we have helps us with the opioid epidemic. I am really proud of the way Indiana responded to that HIV crisis in southern Indiana. We set an example that people across the country have followed. I feel like we’ve saved lives and averted HIV and hepatitis infections across the United States because of our response. Now, with Vice President Pence and I in the positions we’re in, we’re able to highlight the response and also help people understand the real challenges that folks in rural areas face, the real way that culturally people have looked at the opioid epidemic and how you overcome stigma. You don’t overcome stigma by telling them they’re ignorant or by speaking down to them. You bring people along by listening to them and by partnering with them.

You mentioned your naloxone advisory. What more should be done on that front?

We still don’t have all of our first responders carrying naloxone. Every first responder, just as they know CPR, needs to carry naloxone. I’ve often said the biggest killer out there is stigma. Stigma is preventing not only first responders but people in the community from carrying naloxone.

You’ve become a big booster of the U.S. Public Health Service Commissioned Corps, which you’re a leader of. What do you think most Americans don’t understand about what they do?

The corps epitomizes public health in both a positive way and in a negative way. We represent the whole gamut of public health, from engineers to doctors to nurses to pharmacists to environmental health officers. But no one notices you until you’re not there and until something goes wrong. I have tried to use every opportunity to lift up the corps.

How do you navigate supporting the corps when the administration has proposed cutting the number of spots in the corps?

The way I view what the administration has said is that they want us to demonstrate the value of the corps. That’s something we as a service have not done a great job of in the past. We don’t go out and brag that your swimming pool is clean or you were able to eat at that restaurant and not get sick. But sometimes we do have to brag so folks realize it’s worth paying for our services. The president and the administration have a responsibility to spend tax dollars wisely, but [Assistant Secretary for Health Brett] Giroir and I are both confident in the value of the corps and we’re working hard so we can demonstrate that value.

Have you spoken to the White House about that?

I have not spoken with the president, but we’re in constant conversations with the Office of Management and Budget, which put out the initial language. We’re very pleased with where that conversation has gone so far.

What do you think about safe injection sites?

I think we need to focus on something that’s already out there and has been proven to work, and that’s syringe service programs. So …

Right, but I’m specifically asking about …

Let me back up a second. I’ve always said that communities need to have a conversation about the burden of the opioid epidemic and they need to decide what is an appropriate response. In terms of safe injection sites, the administration and the Department of Justice have been very clear that they do not consider them to be legal. From a health point of view, before I get into a back and forth with anyone on safe injection sites, I want to make sure we’re optimizing syringe service programs. Because safe injection sites, when folks describe them working well, they really are just syringe service programs that additionally provide a place for folks to inject, which again has been determined by our Department of Justice to be illegal. I want to make sure we’re providing all those other services that we all agree are appropriate responses — providing clean syringes for folks, providing testing for HIV and hepatitis, providing naloxone, providing connections to care.

(Following the interview, a spokeswoman sent an additional statement from Adams: “As the Nation’s doctor, I want every discussion about public health programs to be based on high-quality scientific evidence. Such evidence must demonstrate effectiveness and safety, as well as examine potential adverse effects on the individual and the community. Currently, that level of evidence does not exist for supervised injection facilities in the United States.”)

Does it concern you that a number of established syringe exchange programs have closed?

It does concern me. We all need to do a better job about having a conversation about the burden of disease and what is an appropriate way to respond. When I see a program close, what that says to me is that we haven’t done a good enough job communicating to the community why this program is important and the value that it provides.

Have you had to wrestle with anything personally serving this administration as a person of color?

To be honest, no. Again, I was at honored at the White House. Not only have I been supported, but I’ve been able to promote my message of health equity for all. I very much believe that if we don’t pay attention to those who are most negatively affected in terms of health risk factors, it’s going to hurt our entire country and our profitability. Framing it that way has resonated very well not only with this administration but all across America.

I’ve been blessed to be in this place at this time, because I feel that based on my background, I’ve been able to communicate a health equity message in a way that folks haven’t been able to communicate before. I’ve been able to resonate with an audience that folks haven’t been able to resonate with before.

I know you’re accepting comments for what will ultimately become a report about how investments in public health help communities’ prosperity. Is that the main project for year two? What else?

That’s going to be huge.

There are two other main projects. I’m really going to lean into this postcard. We aren’t going to solve this opioid epidemic as long as people are pointing fingers and saying it’s someone else’s problem. We need everyone engaged.

The third thing we’re working on is partnering with the military on health and national security. Seventy percent of our 18- to 24-years-olds are ineligible for military service, so our nation’s poor health is not just a threat in terms of chronic disease, but it’s a threat to our national security. A healthier country is a safer and more secure country.