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Surgeon General Vivek Murthy On The Addiction Crisis In America
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Appointed by President Barack Obama, Dr. Vivek Murthy was confirmed on December 15, 2014, as the 19th United States Surgeon General. Being a first generation immigrant from India and the United Kingdom, Dr. Murthy is proud to have assumed the role of "America’s Doctor," responsible for communicating and applying the latest scientific information to help improve personal and public health.
On November 17, 2016, Dr. Murthy released Facing Addiction In America: The Surgeon General’s Report On Alcohol, Drugs, And Health. As the first-ever report of its kind, the goal is to deal with the current national drug crisis, including the opioid epidemic and prescription drug misuse, in the same manner that the famous 1964 Surgeon General’s report confronted the dangers of tobacco use in the country. A few days after the report, Dr. Murthy spoke to The Fix about his findings and what he hopes to accomplish moving forward.
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The decision to issue a report on alcohol, drugs, and health was the first major decision I made after becoming Surgeon General.
As a first-generation immigrant from the United Kingdom whose family moved there from India, you became an American citizen and embraced the American dream. What does it mean for you to have reached the heights of distinction by becoming the Surgeon General? What would you hope other immigrants take from your success?
That’s a great question, and let me say this right away: It is just a great honor to have the opportunity to serve as Surgeon General. For my family, coming from humble roots as they did, this is not an opportunity to serve that they ever expected that I would have, but my parents did come here because they hoped that America would be a place where my sister and I would have opportunities. They believed this country would provide us with opportunities to learn, opportunities to support a family, and opportunities to contribute. I am grateful to say that we have found that and so much more.
What my own immigrant experience reminds me of is that our nation is an incredibly diverse place that has historically been a land of immigrants. We should never forget that everybody has something that they can contribute to our country, whether they came here a year ago or a generation ago or ten generations ago. I try to remind myself of that reality every day, and it’s why I try to make it a point to ensure that I work to create opportunities for as many people as possible to come and serve in government. We need more smart, talented, effective people in government at the local, state, and federal levels. It’s a responsibility of all of us who have had the privilege of serving in government to create opportunities for others.
On November 17, 2016, you released Facing Addiction In America: The Surgeon General’s Report On Alcohol, Drugs, And Health. The first-ever report of its kind, why did you decide to release it and what do you hope to accomplish?
The decision to issue a report on alcohol, drugs, and health was the first major decision I made after becoming Surgeon General. I made that decision because for far too long people with substance use disorders have suffered in the shadows. For too long as a country, we have treated addiction primarily as a criminal justice issue, instead of as the public health issue that it really is. When I issued the report on November 17th, it was time for us to start treating addiction as a chronic illness and not as a moral failing.
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It also was time for us to recognize the scope of our addiction crisis in America. Having traveled across the country, I found that addiction touches all of our communities. At the same time, so many people remain unaware of how widespread this problem is. They often feel that they and their families are one of a small number of folks who are suffering, and, as a result, they end up suffering in silence. In contrast to this mistaken perception, this is a widespread problem. There are 20.8 million people in America who are living with a substance use disorder. Let’s put that number in perspective: that’s more than the number of people who have all cancers combined and it’s similar to the number of people who have diabetes. This is a major public health problem, and it’s time for us to recognize that fact.
Finally, I issued the report because it is time for us to highlight how there are now proven prevention and treatment programs that can help Americans who are living with substance use disorders. The good news is that we now have evidence-based strategies to prevent substance use disorders and to treat them once they develop. The problem, however, is that we are not using them nearly as much as we should. Only 1 in 10 people with a substance use disorder is getting treatment right now; that’s a massive gap that needs to be closed. We also know that prevention and treatment are cost-effective. For every dollar that we spend on treatment, we save four dollars in healthcare costs and seven dollars in criminal justice system costs. On the prevention side, there are programs that return up to $64 for every single dollar invested. When people ask me whether or not we can afford to invest in prevention and treatment programs, I tell them that we can’t afford not to invest in these programs. Substance use disorders are right now costing our country $442 billion dollars a year. Unless we focus on investing in prevention and treatment programs in our communities, we are only going to see that number increase.
You have said, "The most important thing is, we have to change attitudes towards addiction and get people into treatment. Addiction is a disease of the brain, not a character flaw."
How do you believe that the deeply ingrained stigma of addiction—believed to be not a disease but a character flaw—can be overcome?
Eradicating the stigma around addiction is going to require each of us to step up and play a part. What we are talking about here is culture change, and you can’t legislate a change in people’s attitudes or a shift in culture. Culture is formed by the attitudes and beliefs of people all across our country, and that means we actually do have the power to overcome some of these negative attitudes and biases that have developed around addiction.
Shifting how we think about addiction is very important because there are so many people who need treatment, but don’t feel comfortable stepping forward and asking for help because they fear that they will be judged. As I traveled across the country as part of our opioids tour, I met people who were scared to come and talk to me if there was a camera nearby. They were worried that if it became known that they were struggling with a substance use disorder, they would lose their job, be ostracized by their friends and they might even be looked at differently by their doctor. We know the unfortunate stigma around addiction is a problem that is impacting our ability to get people to come forward and ask for help. It’s even difficult to get communities to accept treatment centers in their neighborhoods.
This is why it’s so important for us to make this culture shift about how we think about addiction. The good news is that each of us has the power to make that happen. Each time we take that step and change how we think about and talk about addiction, we give other people the permission to make that shift as well. We give them the opportunity to come forward and share their story, and that is the beginning of healing.
In the report, you urge a holistic approach to battling the addiction epidemic that should involve policy makers, regulators, scientists, families, schools and local communities. Behind such a holistic effort, there needs to be a lot of capital. Despite passing the Comprehensive Addiction and Recovery Act and President Obama signing CARA into law, Congress has not funded the initiatives within. Without money from the federal government as well as state and local support, are these efforts bound to fail?
In the report, we lay out a number of steps that we have to take in order to address the addiction crisis in America. Certainly, many of these require a greater investment by us as a country. We know that in order to ensure that treatment and prevention programs are being utilized in communities all across America it is going to require capital investment. As I mentioned earlier, we know that treatment programs not only are proven to work, but they save lives and money as well. In the report, we have an entire chapter where we describe a number of prevention programs that have already been implemented in communities across the country. These programs all return a range of amounts for the investment, but some of them are up to $64 for every dollar spent. That’s an incredible return on investment. To ensure that these programs are available everywhere, however, we do have to invest as a country.
At the same time, I also want to be clear that there are steps that we call for in the report that actually don’t require further investment from the federal side. For example, we know we need to change the way we see addiction. People can begin to make this change on their own and help to affect their families and their communities. Another step that can be taken involves our recommendations for clinicians in regards to how further training can help them learn how to screen for and diagnose and treat substance use disorders. Such training can be accelerated by medical schools and residency programs right now. We also know that integrating the treatment of substance use disorders with traditional medical treatment is an approach that healthcare providers can begin to take as well. In fact, many healthcare systems have already started doing that in response to shifting payment models that focus on paying more for value as opposed to volume of care. Others have made this shift because they recognize that it’s long past due. They integrate this type of care because it makes it easier for patients to access treatment for substance use disorders.
While federal investment is very important, many steps can be taken within our communities with existing resources. When it comes to this problem, we need to focus on working on all fronts because there is no single solution to addressing addiction in America. It’s going to take all of us working in our traditional roles as well. It’s going to require parents talking to our kids about addiction. It’s going to require teachers and principals leading prevention programs in schools. It’s going to require law enforcement officials to not only equip themselves with naloxone to address the rash of opioid overdoses, but also work with public health officials to get people in need connected to treatment. It’s going to require our healthcare system to provide the best training to our clinicians while offering the integrative care that our patients need and deserve. All of this is in addition to the investment that needs to be made by government so the prevention and treatment services are both provided and adequately funded.
You hope that actions taken in response to the report will mirror actions taken in response to the 1964 Surgeon General's report on tobacco. At that time, 42 percent of the population smoked but few recognized the danger. That report led to decades of effective legislation and efforts to promote tobacco control. Today, the smoking rate has been cut by more than half. Do you see the present report leading to such positive results? What are the biggest barriers?
I’m glad that you brought up the 1964 report because it helps to show how reports by Surgeon Generals have had a long and important history in America, spurring our nation to action on critical public health issues. The 1964 report on tobacco was one great example of that positive action: It helped to spearhead a half-century of work on tobacco control. Right now, this is a time when I believe that our nation has to be called to action to address the addiction crisis and that’s why I issued the report on alcohol, drugs, and health. My hope is that it will move people to not only implement policies and programs that we know work, but also to examine how they think about and talk about substance use disorders in their own lives.
For example, we know that the words we use are powerful tools that shape the environment in which we live. If we talk about addiction as a character flaw or a moral failing, then we intentionally or unintentionally tell people that they will be judged if they come forward and admit that they have a problem. This is exactly why it’s up to us to think about how we’re talking about addiction and to ensure that our words and our actions are being informed by compassion and by science, and not by old misconceptions about addiction. In the report, one of things we lay out is how addiction has a biological basis. It’s a chronic disease of the brain. We know that somewhere between 40 and 70 percent of a person’s individual likelihood of developing a substance use disorder is based in genetics. After the genetic influence, the remainder is governed by other factors, including the environment in which you grew up. Given such factors, you start to realize that any of us could be susceptible to a substance use disorder. It’s a mistake to see it as a path that people always actively choose. Given the conflict of factors, some related to your genetics and some related to your environment, many people can be led beyond choice down the path of addiction. Such a realization helps us to understand that our approach truly needs to be informed by science and by compassion.
In the report, we call for people to accept this approach for thinking about addiction in order to allow science and compassion to properly guide us. My hope is we’ll be able to look back on this report and see how it shined a light on a critical public health challenge. We’ll be able to see how it called our nation to action around both a cultural shift as well as policy and programmatic shifts, and how it ultimately helped to bring people out of the shadows and get them the help that they’ve needed for a long, long time.
The Administration’s response to the opioid epidemic has had a strong emphasis on providing access to medication-assisted treatment (MAT). Is MAT enough? Hasn’t it been shown that MAT, without the support of therapeutic counseling, fails to promote long-term recovery and sustainable sobriety in the majority of patients?
By its very definition, medication-assisted treatment has to include more than medication alone. It has to include counseling services and the other support services that are an important part of effective addiction treatment; that’s an important point because many people do not recognize that aspect of MAT. It does not mean that you can take a pill for a couple of weeks and be cured of your substance use disorder. That’s not actually how it works; in the same way that if you have diabetes, you don’t take a pill for a couple of weeks and you’re cured of your diabetes. It’s a chronic illness that requires long-term management, and the same is true of addiction.
People need to recognize that MAT includes counseling and other services as well as medication, and that it has also been proven to work. We know MAT is effective in reducing the number of overdoses and the number of relapses. It also enables people to ultimately live healthy and productive lives. With effective treatment, we actually can reduce the relapse rates that reflect other chronic illnesses like diabetes and high blood pressure. We certainly need to continue investing in research so we can develop even better treatment strategies, but everyone should know that we have evidence-based strategies right now. This is why it’s so important to raise awareness about the effectiveness of these existing strategies like MAT that do work.
There’s another important point to make as well. People need to know and understand that treatment works. A huge misconception out there about medication-assisted treatment is that it’s not effective. I have heard this misconception time and time again as I’ve traveled across the country. Many people are suspicious of methadone and buprenorphine, and they think that such medication-assisted treatment drugs do not have a place in treatment. They believe in abstinence and abstinence only, but science tells us very clearly that there are multiple paths to recovery. For some people, abstinence might be the right path, but that’s not necessarily the most effective path for everyone. What we care about are what are the strategies that are going to help as many people with substance use disorders as possible to live healthy and productive lives; what strategies will reduce their chances of overdoses and relapses. And fortunately we have multiple strategies that will lead in many cases to those outcomes. Given the success of different strategies with different people, it’s important that we make the options that are available equally accessible to people.
As someone in long-term recovery who works a 12-step program, I completely agree with that perspective. I don’t believe that what has worked for me needs to be what has to work for everyone. Like you, I am much more concerned with saving lives. What’s most important is what works as opposed to some kind of orthodoxy that prevents viable treatment strategies from being implemented.
If you think about it, such a perspective is very similar to how we think about cigarettes. Some people are able to quit cigarettes “cold turkey.” They decide one day that they’re not going to have another cigarette, and they’re able to manage it. We’ve seen clearly, however, that that’s not the best approach for everyone. In fact, many people try to quite cold turkey and end up relapsing later. As people experience that seesaw of going up and down between quitting and relapsing, it often takes quite an emotional toll.
When it comes to quitting cigarettes, this is why using things like nicotine gum or the nicotine patch works well as effective strategies for many people. Other people will find that complete abstinence is the best strategy for them right off the bat. We have different strategies that work for different people. What’s most important is to find treatments that actually work. This is why treatment needs to be tailored to the individual in order to help ensure positive outcomes.
You took the unprecedented step for a Surgeon General by sending a letter in August to almost every health care professional in the country, asking him or her to help solve the problem of opioid addiction. Can you describe the motivations behind sending this letter and what you hope to achieve with the medical community?
In August, I sent a letter to 2.3 million health care professionals, and these included doctors, nurse practitioners, pharmacists, dentists, physician assistants and others as well. I did this because I believed it was important to call the medical profession to take action and address the opioid crisis. They needed to recognize the unique role they have to play given their power to prescribe as well as given their abilities to help inform their patients and communities about important public health matters. In this case, we know that several decades ago clinicians were urged to treat pain more aggressively, but were not necessarily given the tools or training to do so safely. There also was an aggressive marketing of pain medications by pharmaceutical companies to doctors and to others.
When you combine these two factors with our lack of investment as a country in treatment services, plus the ongoing negative attitudes and bias around addiction, it actually came together to prevent us from being able to address the opioid crisis early. As a result, we saw a rapid increase in people addicted to prescription opioids and a rise in injection drug usage. We saw this leading to a significant increase in hepatitis C and HIV infections as well as a rapid rise in the use of heroin. I issued the letter because I felt physicians could play an important role in helping us address the opioid crisis. I wanted to appeal to clinicians directly. I know that most clinicians did not come to their professions because they were looking for a certain social status or even a certain salary. They came because they wanted to help people and they wanted to alleviate suffering. Given this original impulse towards the profession, it’s why I believe many physicians will respond positively to this call to action. I believe they are going to respond and help us turn the tide on the opioid epidemic.
In the letter to the medical professionals, you wrote, “Nearly two decades ago, we were encouraged to be more aggressive about treating pain, often without enough training and support to do so safely. This coincided with heavy marketing of opioids to doctors.” Can you go into greater detail about the history of the problem and how this ultimately destructive medical advice became a national reality?
There was a recognition several decades ago that as a country we were undertreating pain, and it’s worth noting that this remains a problem in certain groups, particularly in minority communities. The problem was that call to more aggressively treat pain was not accompanied by the tools and the training that clinicians needed to make sure they were treating pain safely and effectively. It led to a significant increase in the quantity of opioids prescribed, and it coincided with a significant increase in the number of opioid overdose deaths.
Many clinicians were even taught incorrectly that opioids were not addictive if they were prescribed for "legitimate pain." I remember being taught that during my training, and many of my colleagues were taught that as well. We had to unlearn that, and this is why I believe a big part of the solution will be on training our clinicians more effectively. We also need to provide them with the tools so they can better do their jobs like prescription drug monitoring programs (PDMPs). PDMPs help clinicians understand what kind of opioid prescriptions their patients might be getting from other healthcare providers.
In the letter, you asked doctors to take the following pledge to:
- Educate ourselves to treat pain safely and effectively.
- Screen our patients for opioid use disorder and provide or connect them with evidence-based treatment.
- Talk about and treat addiction as a chronic illness, not a moral failing.
Why aren’t doctors better educated when it comes to pain management? Is this the fault of medical schools or due to the influence of the pharmaceutical industry? Do you believe greater awareness by doctors can affect the opioid epidemic in a positive way?
Doctors can help us address the opioid crisis because they have always been on the front lines of dealing with a range of public health issues that face our country. It takes time to ensure that the rapidly evolving health needs of the nation are adequately reflected in the kind of training that we give our clinicians and in the kind of health system that we build to address the needs of patients. This is part of the work we have to do now in relation to the current opioid crisis specifically and the substance use disorder challenges in general. We need to ensure that we are providing more support.
Every doctor that I speak with wants to be able to alleviate pain and suffering in the patient that’s in front of them. They want to be able to care for someone’s pain in as safe a way as possible. Nobody wants to be part of contributing to a substance use disorder or addiction, and this is why we’ve seen such a positive response from medical schools across the country. They are stepping up to be a part of the solution, and they are doing that by expanding their curriculum to offer more of a focus on substance use disorders. Individual clinicians also are taking more time to talk to the patients in their practice about the problem. They are screening them for substance use disorders and doing their best to offer treatment options when they uncover such issues. Many clinicians are calling upon their healthcare systems to integrate the treatment of substance use disorders into the traditional medical care system. They want to make sure that treatment is available to more patients that need it. I have always believed that doctors can be a powerful force for positive change, and not just in their individual practice, but also at a community, state and national level.
In the opioid pledge, you discuss the importance of better screening. Wouldn’t better screening be easier if there existed a national database of prescription information and patient histories, easily accessible to doctors online?
This is a great question. Right now, we have a state-based system for prescription drug monitoring programs, and some of these state-based PDMPs are connected to each other, but not all of them are. It has proven to be a problem for many clinicians, particularly when they live in parts of a state that are close to other neighboring states. Right now, I am speaking to you from Washington, D.C. where it’s a short drive to either Virginia or Maryland. As a result, information about prescribing need to be shared by the states in this area. Such a sharing of information helps a doctor be confident that patients are not taking advantage of the system in order to get more prescription drugs. Doctors need to be confident about the prescribing history of their patients that they see in the database in front of them.
While strengthening the connection between state systems, we also need to ensure that the data contained in the PDMPs is both in real time while being integrated with existing electronic health records. Many states still have a time lag between when a prescription is written at a specific location and when it is updated into the PDMP database. Such a time lag creates risk. We also know that not integrating PDMPs into the existing electronic health record system results in additional steps for clinicians to take. Such additional steps in the midst of a busy clinical day can mean more barriers that can lead to increased risk as well, preventing safe and effective prescribing of opioids. What I would like to point out is that the Obama administration has been very focused since the beginning on funding PDMPs across the country, helping out the states. We have made good progress, and we need to continue on that path. We need PDMPs in real time that talk to each other and are integrated into our greater health system.
At the United to Face Addiction Rally in Washington, you said, “I learned that there is no single face of addiction, it impacts all of us, and our families.” How does the diverse nature of addiction as a disease affect prevention efforts? How does the breadth of those impacted make it harder to raise awareness?
The fact that addiction affects people of all backgrounds, including all races and ethnicities, all socioeconomic levels and all regions in our country, should make it an issue we can all come together around. The problem is that so many people in the country do not realize how widespread the addiction crisis is because of the unfortunate negative attitudes and biases that we have around the disease. People’s core beliefs about addiction, all of those negatives that we have discussed, make it hard for them to talk about it. As I travel, I discover that there are so many people around the country suffering in silence. They are isolated, and they mistakenly think that they are the only ones being impacted by addiction. They are ashamed to come forward and admit that they have a problem. What they so often do not see is that there are other people in their neighborhoods and their social circles who have a substance use disorder and who are suffering in silence in well. The more people that are able to come forward, the more that silent suffering will be reduced as the awareness of the problem is increased and raised. The more we share our stories and talk about addiction with each other, the easier it will be for the people that need help to come out of the shadows and ask for that help.
This is why the culture shift is so important. This is why we need to move together and take these actions because lives are truly at risk. Right now, addiction is affecting communities all across America, but people don’t want to talk about it because they are scared. We have to make it okay to talk about addiction. We have to make people realize that what they have is a chronic illness and not something to be ashamed of. We have to help people come forward and tell their stories so everyone can understand the true nature of addiction. If we can help people make this cultural shift, we’ll see more organized collective efforts in communities across America to ensure that we are taking the steps to both prevent addiction and treat it as a chronic illness when it arises.
On October 4, 2015 at the same rally, you also said, “I learned that recovery takes hope to get us through the moments when we’re not sure we can make it. I learned that recovery is about community.”
What needs to be done to turn local communities into effective defenses against the national drug abuse epidemic?
I think the most effective weapon we have in the fight against addiction is compassion, and it plays an essential role in how local communities need to address the problem. Compassion is what allows us to stop judging and to start helping. We need local communities to become sources of compassion and understanding. We need them to do that by sharing not just the stories of heartbreak, but also the stories of hope and recovery. Like your own story, John, there are many of those stories out there, and I have the privilege of hearing them as I travel across the country. I have found that some of the most inspiring people I have met in communities across America are those that have turned their pain into a passion for helping others. We need to tell more of those stories.
We also need to embrace each other, recognizing that all of us could have had a substance use disorder if we had simply been born into different circumstances or born with a slightly different genetic makeup. We need to recognize that because it opens the door to our being able to embrace each other and support each other. We need to help each other through the process of treatment, recovery and healing. People need to understand that you don’t need to have a medical or public health degree in order to address this issue. What you need at the most basic level is kindness and compassion and a willingness to recognize that we need to come together to address a crisis that is touching all parts of America. The most powerful force that we have in our country is not our dollars or our military: It’s our people and their ability to come together and create change at the local level. Such a strength is what ultimately will allow us to address the addiction crisis. I want people to remember that they have the power to help us turn the tide on this crisis. The only way we are going to do that is if people from communities all across America stand up and become a part of the solution.