U.S. Surgeon General Shares 5 Lessons All Physicians Can Take From the Opioid Epidemic

What does the 2019 measles outbreak have to do with cardiovascular care? More than meets the eye, according to U.S. Surgeon General Jerome Adams, MD, MPH, in comments at a recent healthcare policy grand rounds at Cleveland Clinic’s Miller Family Heart & Vascular Institute.

“I never thought I’d be dealing with measles as surgeon general in 2019, but here we are,” said Dr. Adams (second from left in the photo above). “Even though this is a cardiovascular crowd, we all have a role to play in lifting up the importance of vaccinations, because this is what happens when we don’t speak up for public health and support proven interventions. We start to backslide, and before long we have a measles outbreak going on.”

Surgeon General Adams, who trained as an anesthesiologist, said there’s a similar universality to the nation’s opioid epidemic, noting that it carries important implications for physicians across all disciplines, including cardiovascular disease. He explored those implications in a panel discussion at the grand rounds event with several leading Cleveland Clinic physicians and a Cleveland city councilman. At least five key takeaways emerged, as recapped below.

1) Carrying naloxone should become as common as getting trained in CPR

Dr. Adams began by asking for a show of hands of how many grand rounds attendees knew CPR — and then how many carried the overdose-reversing drug naloxone with them everywhere they go. The difference in the show of hands was stark, in favor of CPR.

“The chances are much greater you’re going to hear that someone’s overdosing in a bathroom and needs help than you’re going to be told someone needs CPR,” said the surgeon general, noting reports of eight overdoses in the city of Cleveland the preceding weekend. “We need to start walking the talk on this,” he said, citing his recent advisory calling on healthcare providers and people who come into contact with individuals at risk for opioid overdose to learn how to use naloxone — now available in easy-to-use intranasal and auto-injector formulations — and to keep it within reach.

“Any of us can obtain naloxone from a pharmacy and carry it,” Dr. Adams said. “Doing so can save a life. I have seen that the communities across the country that turn around their opioid overdose rates are the ones that start by saturating the community with naloxone. The only way we’re going to turn around this opioid epidemic is if we’re all willing to do our part.”

Cleveland Clinic Heart & Vascular Institute Chair Lars Svensson, MD, PhD, who moderated the grand rounds session, commended the suggestion and said his institute would explore providing naloxone for all its physicians to carry.

2) The epidemic presents opportunities for upstream interventions

Dr. Adams pointed out that he made substance misuse one of his priorities as surgeon general because it’s often a symptom of upstream issues and an opportunity to address those issues. “The opioid epidemic is a terrible tragedy,” he said, “but it also presents a chance to help people understand the need to address mental health, adverse childhood experiences, trauma and other contributing issues. If we use the opioid epidemic to talk about how we can get into the community and work upstream to prevent disease from occurring, we may end up with less cardiovascular disease and cancer along with less opioid misuse.

“The majority of health is behavior and environment — what we call the social determinants of health,” he continued. “I urge you to find out more about your patients’ social needs and how you can lean into more upstream interventions. Take endocarditis: Nationwide, fewer than 10% of people who undergo valve surgery for opioid-related endocarditis get referred to medication-assisted treatment for opioid misuse.”

Lack of such upstream intervention can contribute to provider burnout, he noted. “No matter how good a job you do treating endocarditis surgically, you’ll end up feeling like you’re on a hamster wheel if you keep having to treat a patient again and again for the same thing. The key is to help ensure effective intervention to stop the cycle. In addition to saving lives, that will make for greater job satisfaction and less burnout.”

3) Providers need to pay attention to their biases

When the averages improve on a public health challenge like opioid misuse, Dr. Adams noted, too often health disparities persist or go up, because resources tend to go to the communities that can most afford them. “Before we pat ourselves on the back too soon,” he said, “we must pay attention to the biases that exist in our communities” and make sure progress is reaching those without ready access to academic medical centers and the best providers and resources.

Beyond being the right thing to do, tending to such biases can prove to be in everyone’s self-interest: If health disparities are not addressed, other panelists noted, they ultimately may reach beyond low-resource populations and affect the broader community as well.

The need for attention to biases also extends to personal interactions with patients. “We need to avoid language that stigmatizes or dehumanizes patients who are struggling with opioid use disorder,” said panelist Steven Gordon, MD, Chair of Infectious Disease at Cleveland Clinic. “We must always recognize our patients as individuals and be open to learn from them.”

That advice resonated with co-panelist Gosta Pettersson, MD, PhD, a cardiothoracic surgeon who directs Cleveland Clinic’s Endocarditis Center. “Beyond operating on a patient’s endocarditis to help them survive and avoid complications,” Dr. Pettersson said, “we have another powerful tool at our disposal — the ability to actually connect with patients. If we show these patients that we see them as valuable human beings and we’re not giving up on them, that can help save their lives in the long run. It can matter as much as saving them through surgery in the short run. Just the other day one of my endocarditis patients called to tell me they’ve been drug-free for 22 months. This shows we can have an impact.”

4) Don’t try to do it all yourself

“I don’t want folks leaving here thinking they have to do everything themselves,” said Surgeon General Adams. “You don’t. There are community health workers. There are peer recovery support services. We just need to do a better job connecting patients with the resources that already exist in the community and ensuring a good handoff.”

That advice was echoed by panelist David Streem, MD, a psychiatrist who directs Cleveland Clinic’s Alcohol and Drug Recovery Center. “We now have peer support in our emergency departments, and it has been tremendously helpful for these patients,” he said. “And being able to work with patients who are hospitalized for endocarditis gives psychiatrists like me a chance to have a profound impact on individual lives.”

5) Consider new approaches to care

Panelist Adam Myers, MD, Chief of Population Health for Cleveland Clinic, pointed out that the long-standing opioid crisis has created a growing number of people who are recovered or recovering addicts who someday may need to undergo procedures that require pain management. “Too often we do not do a good job accounting for their history of addiction when we treat them again,” he said. “We would do well to focus on behavioral medicine approaches and finding opioid replacements and other ways of mitigating pain for these patients instead of acting reflexively.”

Surgeon General Adams concurred. “We may need to come up with a new specialty of providers trained to deal with folks who are now in recovery,” he said. “We need providers like you here at Cleveland Clinic to help design the best models of care for the many patients in this new situation.”