Time to Put the Surgeon General in the Game

President Donald Trump is the third president in a row, in the humble opinion of Youth Services Insider, to make an interesting and exciting pick for Surgeon General. Jerome Adams, the former health commissioner for Indiana, is a young choice at age 42 with bipartisan plaudits for his connection to the community.

And if recent history is our guide, he will have no profile and little impact. Far from its heyday of relevance, when most Americans knew the name of Reagan’s top doc, C. Everett Koop, recent administrations have been content to have the most public day of their Surgeon General’s term be the day they were nominated.

Facing a well-publicized increase in drug overdoses, an issue that Adams has tackled directly in Indiana, it would be a nice time for the Surgeon General’s office to wield some influence and clout.

There are really two ways that a Surgeon General can have an impact. The first is through the real lasting legacy of anyone in that job: his or her published reports, which place the weight of the executive branch behind conclusions drawn from science and research. The other is the bully pulpit: public speaking, appearances in the media, etc.

Bill Clinton’s pick, David Satcher, was not exactly a compelling public figure in the mold of Koop. But he did crank out more than a dozen official reports from 1998 to 2002, several of which were focused on youth, including timely looks at children’s mental health and youth violence.

George W. Bush tapped Richard Carmona as his Surgeon General, and YSI recalls thinking that he was a guy whose profile suggested both the potential for a dynamic role and a future in politics. Carmona is an Army Green Beret veteran who went on to serve as the SWAT team training officer in Pima County, Ariz., and then became a trauma physician in Pima County.

But Carmona was hardly heard from. One staffer who worked closely with him said that in the tightly controlled Bush administration, a charismatic guy like Carmona would never be allowed to outshine higher-ups on the health chain, such as Health and Human Services Secretary Tommy Thompson, who left in January 2005.

“Let me put it this way,” Pima County Sheriff Clarence Dupnik told the Arizona Daily Star in 2004. “I don’t think this administration is using Carmona’s many talents. My observation is that he is part of an organization that is very tightly controlled by a handful of people.”

Paper output from the office was equally lacking. Satcher released 14 official reports from 1998 to 2002; over the same amount of time, Carmona produced two studies: one on secondhand smoke and another on osteoporosis. He ran for a Senate seat in Arizona in 2012, and lost to Sen. Jeff Flake (R).

President Obama pondered the first appointment of an already-famous person to head the office: Dr. Sanjay Gupta, a neurosurgeon and chief medical correspondent for CNN. That would have been an interesting test, because Gupta is way too high-profile and media-connected to be easily sidelined by HHS leadership. And perhaps that’s why he passed on the job, withdrawing his name from consideration.

Obama’s ultimate choice, Regina Benjamin, was also great. Benjamin, who holds degrees in medicine and business, won a MacArthur Genius Award for the rural health clinic she started in Bayou La Batre, Ala.

Youth advocates were encouraged by the pick.

“We need a strong advocate, which I think we now have, that understands the barriers that face so many children and youth in getting access to quality health care,” Dr. Irwin Redlener, co-founder of the New York-based Children’s Health Fund, told YSI at the time.

Between 2009 and 2013, the office pumped out one report on suicide prevention, and two about smoking, including one that specifically honed in on youth smoking.

By our count, they were the 31st and 32nd Surgeon General reports on smoking and tobacco; two more have been published since. Not to diminish the need to prevent youth from heading down the path toward lung cancer, but we are past the point of needing the Surgeon General to hammer home the research on this.

In April of 2013, YSI was told by Benjamin’s office that the Surgeon General was planning to focus on several youth-related issues during Obama’s second term. On the calendar were reports about prescription drug use by youth, underage drinking and another look at youth violence, which Satcher had tackled under Clinton.

Benjamin resigned three months later, and none of those reports came out.

Obama’s second confirmed Surgeon General, Vivek Murthy, confirmed in 2014, spent his two years on the job amassing an 800-page tome on the causes, and ways to prevent and treat, addiction in America.

Last month, in a widely published op-ed, Murthy slammed the Republican health care bills for allowing states to remove addiction treatment as an essential health benefit.

Enter Jerome Adams, a young anesthesiologist from the Western Shore of Maryland who will almost certainly be our 20th Surgeon General. Pence, then governor of Indiana, tapped Adams to be health commissioner in 2014. He is credited with bringing Pence around on needle exchanges during an HIV crisis prompted by the opioid crisis.

For the full story on what happened, check out the podcast on the subject produced by Embedded; it really is a fantastic piece of journalism. Here’s the quick gist though.

The opioid of choice in Scott County, Ind., was Opana ER, a painkilling opioid manufactured by Endo Pharmaceuticals. Just last week, Opana was voluntarily taken off the market by Endo due to concerns about misuse.

In a previous attempt to abuse-proof Opana, Endo changed the pill’s coating so it was basically impossible to crush up and snort. In Scott County, this prompted a surge in users who were melting the pills down and injecting it.

And the lack of clean syringes, in turn, prompted a terrifying surge in HIV cases in the county. In the span of a year between 2014 and 2015, the number of documented HIV infections in the small county went from 26 to 158. Adams declared an HIV outbreak.

Pence had moral reservations about needle exchanges. Beth Meyerson, co-director of Indiana University’s Rural Center for AIDS/STD Prevention, told Healthcare Finance News that Adams was the reason it happened.

“Dr. Adams navigated the very ideological political environment that was created by then-governor Pence,” she said. “There’s just no doubt the governor wouldn’t have listened to me or listened to the leaders in the Legislature, but he would listen to Jerome Adams.”

President Trump made combatting the opioid epidemic a part of his presidential platform, and Adams is more familiar this crisis than perhaps anyone in this administration. So if he has the same opportunity to advise Trump as he did with Pence, what will he counsel?

His interview with Jessica Wapner, part of a story published by Mosaic Science, suggests a combination of fraud protection and more spending. Here is a section of note from the article:

Adams told me the problem was exacerbated by physicians themselves. Many opioid prescriptions start out as legitimate treatments for pain. Most doctors are untrained in pain management and yet patient satisfaction scores for physicians, maintained by the Centers for Medicare and Medicaid Services, are directly determined by patients’ assessment of how well their pain was managed.

That score has consequences: a low one leads to a decrease in pay. “We have an environment where doctors and hospitals feel compelled to continue to prescribe opioids based on their bottom line,” said Adams. “We still haven’t accepted that overprescribing is a part of the problem to the degree that I think it clearly is.”

In addition, addiction treatment services have been lacking. In the entire state of Indiana, there are two or three psychiatrists specializing in addiction. “We’ve underfunded mental health and substance abuse for decades,” Adams said.

When Koop headed the Surgeon General’s office, the avenues for advancing health science messaging were slim. CNN was not even a decade old. There were a few news channels, radio, newspapers, magazines, and billboards.

Today, there are several channels doing news 24-7, social media, podcasts, online blogs and news websites. And there’s even a few newspapers and magazines kicking around.

There is no question that the public health crisis of the day is drug addiction. And on Murthy’s watch, the office weighed in with a massive manifesto for better preventing, understanding and treating addiction. Adams can build off the published product by being an effective communicator in the federal fight against addiction, something that Trump has said he intends to take seriously.

Now we’ll see if the Trump administration puts Adams in the game, or leaves him on the sideline.