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U.S. Surgeon General on Emotional Well-Being and Fighting the Opioid Epidemic

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From September 2019 to September 2020, the Centers for Disease Control and Prevention reported nearly 90,000 overdose deaths in the United States. These latest data on the nation’s opioid crisis offer another stark reminder that help is desperately needed in communities across the land. NIH’s research efforts to address the opioid crisis have been stressed during the pandemic, but creative investigators have come up with workarounds like wider use of telemedicine to fill the gap.

Much of NIH’s work on the opioid crisis is supported by the Helping to End Addiction Long-term (HEAL) Initiative. Recently, the more-than 500 investigators supported by HEAL came together virtually for their second annual meeting to discuss the initiative’s latest research progress and challenges.

As part of the meeting, I had a conversation with Dr. Vivek Murthy, the U.S. Surgeon General. Dr. Murthy served as the 19th U.S. Surgeon General under the Obama Administration and was recently confirmed as the 21st Surgeon General under the Biden Administration. In his first term as America’s Doctor, in which I had the privilege of working with him, Dr. Murthy created initiatives to tackle our country’s most urgent public health issues, including addiction and the opioid crisis. He also issued the nation’s first Surgeon General’s Report on addiction, presenting the latest scientific data and issuing a call to action to recognize addiction as a chronic illness—and not a moral failing.

In 2016, Dr. Murthy sent a letter to 2.3 million healthcare professionals urging them to join a movement to tackle the opioid epidemic. This was the first time in the history of the office that a Surgeon General had issued a letter calling the medical profession to action on this issue. In 2017, Dr. Murthy focused his attention on chronic stress and isolation as prevalent problems with profound implications for health, productivity, and happiness.

Our conversation during the HEAL meeting took place via videoconference, with the Surgeon General connecting from Washington, D.C., and me linking in from my home in Maryland. Here’s a condensed transcript of our chat:


Collins: Welcome, Dr. Murthy. We’ve known each other for a few years, and I know that you’ve talked extensively about the national epidemic of loneliness. What have you learned about loneliness and how it affects our emotional wellbeing?

Murthy: Thanks, Francis. Loneliness and perceived social isolation are profound challenges for communities struggling with addiction, including opioid use disorders. I had no real background in these issues when I started as Surgeon General in 2014. I was educated by people I met all across the country, who in their own way would tell me their stories of isolation and loneliness. It’s a common stressor, especially for those who struggle with opioid use disorders. Stress can be a trigger for relapse. It’s also connected with overdose attempts and overdose deaths.

But loneliness is bigger than addiction. It is not just a bad feeling. Loneliness increases our risk of anxiety and depression, dementia, cardiac disease, and a host of other conditions. However you cut it, addressing social isolation and loneliness is an important public-health issue if we care about addiction, if we care about mental health—if we care about the physical wellbeing of people in our country.

Collins: Vivek, you made the diagnosis of an epidemic of American loneliness back before COVID-19 came along. With the emergence of COVID-19 a little more than a year ago, it caused us to isolate ourselves even more. Now that you’re back as Surgeon General and seeing the consequences of the worst pandemic in 103 years, is loneliness even worse now than before the pandemic?

Murthy: I think there are many people for whom that sense of isolation and loneliness has increased during the pandemic. But the pandemic has been a very heterogenous experience. There are some people who have found themselves more surrounded by their extended family or a close set of friends. That has been, in many ways, a luxury. For many people who are on the frontlines as essential workers, whose jobs don’t permit them to just pick up and leave and visit extended family, these have been very stressful and isolating times.

So, I am worried. And I’m particularly worried about young people—adolescents and young adults. They already had high rates of depression, anxiety, and suicide before the pandemic, and they’re now struggling with loneliness. I mention this because young people are so hyperconnected by technology, they seem to be on TikTok and Instagram all the time. They seem to be chatting with their friends constantly, texting all the time. How could they feel isolated or lonely?

But one of the things that has become increasingly clear is what matters when it comes to loneliness is the quality of your human connections, not the quantity. For many young people that I spoke to while traveling across the country, they would say that, yes, we’re connected to people all the time. But we don’t necessarily feel like we can always be ourselves in our social media environment. That’s where comparison culture is at its height. That’s where we feel like our lives are always falling short, whether it’s not having a fancy enough job, not having as many friends, or not having the right clothing or other accessories.

We talk a lot about resilience in our country. But how do we develop more resilient people? One of the keys is to recognize that social connections are an important source of resilience. They are our natural buffers for stress. When hard things happen in our lives, so many of us just instinctively will pick up the phone to call a friend. Or we’ll get into the car and go visit a member of our family or church. The truth is, if we want to build a society that’s healthier mentally and physically, that is more resilient, and that is also more happy and fulfilled, we have to think about how we build a society that is more centered around human connection and around relationships.

My hope is that one of the things we will reevaluate is building a people-centered society. That means designing workplaces that allow people to prioritize relationships. It means designing schools that equip our children with social and emotional learning tools to build healthy relationships from the earliest ages. It means thinking about public policy, not from just the standpoint of financial impact but in terms of how it impacts communities and how it can fracture communities.

We have an opportunity to do that now, but it won’t happen by default. We have to think through this very proactively, and it starts with our own lives. What does it mean for each of us to live a truly people-centered life? What decisions would we make differently about work, about how we spend time, about where we put our attention and energy?

Collins: Those are profound and very personal words that I think we can all relate to. Let me ask you about another vulnerable population that we care deeply about. There are 50 million Americans who are living with chronic pain, invisible to many, especially during the pandemic, for whom being even more isolated has been particularly rough—and who are perhaps in a circumstance where getting access to medical care has been challenging. As Surgeon General, are you also looking closely at the folks with chronic pain?

Murthy: You’re right, the populations that were more vulnerable pre-pandemic have really struggled during this pandemic—whether that’s getting medications for treatment, needed counseling services, or taking part in social support groups, which are an essential part of the overall treatment approach and staying in recovery. It’s a reminder of how urgent it is for us, number one, to improve access to healthcare in our country. We’ve made huge strides in this area, but millions are still out of reach of the healthcare system.

A potential silver lining of this pandemic is telemedicine, which has extraordinary potential to improve and extend access to services for people living with substance use disorders. In 2016, I remember visiting a small Alaskan fishing village that you can only get to by boat or plane. In that tiny village of 150 people, I walked into the small cabin where they had first-aid supplies and provided some basic medical care. There I saw a small monitor mounted on the wall and a chair. They told me that the monitor is where people, if they’re dealing with a substance use disorder, come and sit to get counseling services from people in the lower 48 states. I was so struck by that. To know that telemedicine could reach this remote Alaskan village was really extraordinary.

I think the pandemic has accelerated our adoption of telemedicine by perhaps five years or more. But we must sustain this momentum not only with investment in broadband infrastructure, but with other things that seem mundane, like the reimbursement structure around telemedicine. I talk to clinicians now who say they are seeing some private insurers go back on reimbursement for telemedicine because the pandemic is starting to get better. But the lesson learned is not that telemedicine should go away; it’s that we should be integrating it even more deeply into the practice of medicine.

The future of care, I believe, is bringing care closer to where people are, integrating it into their workflow, bringing it to their homes and their neighborhoods. I saw this so clearly for many of the patients I cared for who fell into that category of being in vulnerable populations. They were working two, three jobs, trying to take care of their children at the same time. Having a conversation with them about how they could find time to go to the gym was almost a laughable matter because they were literally dealing with issues of survival and putting food on the table for their kids. As a society we have to do more to understand the lives of people who fall into those categories and provide services that bring what they need to them, as opposed to expecting them to come to us.

If we continue in a purely fee-for-service-based environment where people must go multiple places to get their care, we will not ultimately get care to the vulnerable populations that have struggled the most and that are hoping that we will do better this time around. I think we can. I think we must. And I think COVID may just be, in part, the impetus to move forward in a different way that we need.

Collins: Let’s talk a minute about the specifics of the opioid crisis. If we’re going to move this crisis in the right direction, are there particular areas that you would say we really need more rigorous data in order to convince the medical care system—both the practitioners and the people deciding about reimbursement—that these are things we must do?

Murthy: There are a few areas that come to mind, and I’ve jotted them down. It is so important for us to do research with vulnerable populations, recognizing they often get left out. It’s essential that we conduct studies specifically for these populations so that we can better target interventions to them.

The second area is prevention programs. People want to prevent illnesses. I have not met anybody anywhere in the United States who has said, “I’d rather get diabetes first and treat it versus prevent it in the first place.” As silly as that might sound, it is the exact opposite of how we finance health interventions in our country. We put the lion’s share of our dollars in treatment. We do very little in prevention.

The third piece is the barriers faced by primary-care clinicians, who we want to be at the heart of providing a lot of these treatment services. I’ll tell you, just from my conversations with primary-care docs around the country, they worry about not having enough for their patients in the way of social work and social support services in their offices.
Finally, it has become extraordinarily clear to me that social support is one of the critical elements of treatment for substance use disorders. That it is what helps keep people in recovery. I think about the fact that many people I met who struggle with opioid use disorders had family members who were wondering how they could be helpful. They weren’t sure. They said, “Should I just keep badgering my relative to go to treatment? Should I take a tough love approach? What should I do to be helpful?”

This actually is one of the most pressing issues: social support is most often going to come from family, from friends, and from other community members. So, being able to guide them in an evidence-based way about what measures, what forms actually can be helpful to people struggling with opioid use disorders could also be immensely helpful to a group that is looking to provide assistance and support, but often is struggling to figure out how best to do that.

Collins: Vivek, you were focused as Surgeon General in the Obama Administration on the importance of changing how America thinks about addiction—that it is not a moral failing but a chronic illness that has to be treated with compassion, urgency, skill, and medical intervention. Are we getting anywhere with making that case?

Murthy: Sometimes people shy away from addressing the stigma around addiction because it feels too hard to address. But it is one of the most important issues to address. If people are still feeling judged for their disorders, they are not going to feel comfortable coming forward and getting treatment. And others will hesitate to step up and provide support.

I will always remember the young couple I met in Oklahoma who had lost their son to an opioid overdose. They told me that previously in their life whenever they had a struggle—a job loss or other health issue in the family—neighbors would come over, they would drop off food, they would visit and sit with them in their living room and hold their hands to see if they were okay. When their son died after opioid use disorder, it was silent. Nobody came over. It’s a very common story of how people feel ashamed, they feel uncomfortable, they don’t know quite what to say. So they stay away, which is the worst thing possible during these times of great pain and distress.

I do think we have made progress in the last few years. There are more people stepping forward to tell their stories. There are more people and practitioners who are embracing the importance of talking to their patients about substance use disorders and getting involved in treating them. But the truth is, we still have many people in the country who feel ashamed of what they’re dealing with. We still have many family members who feel that this is a source of shame to have a loved one struggling with a substance use disorder.

To me, this is much bigger than substance use disorders. This is a broader cultural issue of how we think about strength and vulnerability. We have defined strength in modern society as the loudest voice in the room or the person with the most physical prowess, the person who’s aggressive in negotiations, and the person who’s famous.
But I don’t think that’s what strength really is. Strength is so often displayed in moments of vulnerability when people have the courage to open up and be themselves. Strength is defined by the people who have the courage to display love, patience, and compassion, especially when it’s difficult. That’s what real strength is.

One of my hopes is that, as a society, we can ultimately redefine strength. As we think about our children and what we want them to be, we cannot aspire for them to be the loudest voice in the room. We can aspire for them to be the most-thoughtful, the most-welcoming, the most-inviting, the most-compassionate voice in the room.

If we truly want to be a society that’s grounded in love, compassion, and kindness, if we truly recognize those as the sources of strength and healing, we have to value those in our workplaces. They have to be reflected in our promotion systems. We have to value them in the classroom. Ultimately, we’ve got to build our lives around them.

That is a broader lesson that I took from all of the conversations I’ve had with people who struggle with opioid use disorders. What I took was, yes, we need medication and assisted treatment; yes, we need counseling services; yes, we need social services and wraparound services and recovery services. But the engine that will drive our healing is fundamentally the love and compassion that come from human relationships.

We all have the ability to heal because we all have the ability to be kind and to love one another. That’s the lesson that it took me more than two decades to learn in medicine. More important than any prescription that I could write is the compassion that I could extend to patients simply by listening, by showing up, by being present in their lives. We all have that ability, regardless of what degrees follow our name.

Collins: Vivek, this has been a wonderful conversation. We are fortunate to have you as our Surgeon General at this time, when we need lots of love and compassion.

Murthy: Thank you so much, Francis.


Links:

Opioids (National Institute on Drug Abuse/NIH)

Opioid Overdose Crisis (NIDA)

Vice Admiral Vivek H. Murthy (U.S. Department of Health and Human Services, Washington, D.C.)

Helping to End Addiction Long-term (HEAL) Initiative (NIH)

Video: Emotional Well Being and the Power of Connections to Fight the Opioid Epidemic (HEAL/NIH)

8 Comments

  • nancyhoving says:

    Treatment programs, residential as well as out patient need funding desperately but this administration is doing NOTHING! What about an appointment of a top flight addiction expert being appointed Czar with control of all programs related to substance abuse including budgets in all federal programs who relate to this issue at all.

  • Helen S. says:

    I understand that there’s a problem with illegal opioids but I m on an opioid and closely monitored by my PCP. Yet she is under orders to get me off my meds. I’m very scared because I don’t know how I will function bc of my pain. I can’t walk a half a block now . I used to walk miles before my back injury. Why are people in real pain being targeted? I’d much rather be active and have my old life back.

  • richard says:

    i love the blog . . .

  • Lisa says:

    No one really addressed chronic pain and the need for treatment to be continued for cpps. Chronic intractible pain patients are still being denied medications that allow them quality of life. The CDC gls and the state laws have made getting treatment for painful diseases all but impossible. Many citizens including veterans have taken their lives because they could not live in horrible pain. The CDC gls need to be rescinded and normal prescribing allowed to be able to care for those with painful diseases. To do anything else but treat people’s pain is sadistic and inhumane. If we do not return to a more compassionate practice of medicine so many more will suffer. We are encouraging the ignoring of pain to the point people have died from being judged and turned out of hospitals, when they had a genuine emergency. Do you not see how you created another entire other population to be stigmatized? And that is okay? Even though you have no real proof the people with addiction have gotten any better at all by demonizing what you think caused their said addiction? And that is opinions that all these people got addicted by taking pain medication, not facts. The facts say different, that many were doing other types of drugs/alcohol first . . .

  • Sugath Rajapakse says:

    Very sad isn’t it? Both Dr. Collins and Dr. Murthy are are going around the effects but hardly any talk about where the cause is? Of course both talk of Opioid crisis and addiction and mostly the symptoms, but not having any idea where the cause is? Without a cause there is no effect.
    The cause is the negatively illustrated consciousness. It is the illustration of Name & Form-Perceptions that are in our consciousness which leads to mind formation. From the childhood as you can read from this discussion, it is nothing but negative illustrations from Facebook, WhatsApp, TikTok Twitter and all that and this social media though connecting people virtually does not provide any substance for happy connections, but more so unhappy connections leading to all the stress.

    You cannot kick out social media as they are here, but you can strengthen the consciouness with positive Name& Form-Perception illustrations from the school days. That is Meditation of Mindfulness which helps them to develop mindfulness and concentration and Vipassana leading to knowing the nature of mind and tame it.

  • S.Daniel says:

    Once again, chronic pain patients & the question of their quality of life is completely ignored & side stepped. It’s all about addiction & be damn anyone else that suffers from anything but addiction. Frankly, the war on drugs caused this fentanyl crisis & OD crisis & the very fact, these so called professionals are STILL erroneously regurgitating & falsely propagating the blanket term ‘opioids’ to encompass a broad range of everything from illicit to prescription to heroin to Vicodin is part of the huge problem. If we’re unwilling to even be specific & honest about what people are actually dying & IDing of, we can further expect the results to be more of the same. It’s really a national shame the CDC still continues to deny the data that proves prescriptions never were the problem . . . never differentiated between illicit deaths, drug treatment OD deaths from prescriptions. What a crying shame, all this time raiding grandma’s medicine cabinet when illicit fentanyl was doing the killing. The CDC’S 2016 disastrous opioid guidelines drove hundreds of thousands of addicts to the street to die an early fast death, driving the demand for cartels to make more & more deadly illicit laced tainted fentanyl & carfentenil logs. Restricting & prohibiting safe prescription opioids literally made the problem worse & drove addicts straight to their death & continues to drive illegal demand for easy access illicits dope that addicts will continue to assuredly die on. The stats & data prove it. Just like clean, safe access to needles works & saves lives, so does safe supply & access to prescription opioids. Had the government not cut off addicts & went further cutting off non-addicts from their quality of life meds they’re dependent on from incurable chronic disease like sickle cell, CKD, arthritis & Ms, all those people would be alive & not driven to the street to by untested, tainted, instantaneous death via illicit fentanyl & heroin. No one was dying or dropping like flies from prescription opioids . . . The data shoes more than half those 90K died of illicit drugs, not prescriptions. A third died of a poly cocktail of drugs that included multiple illicits & unprescribed opioids. Then the remaining actually died of treatment for addiction opioids like liquid methadone & Suboxone & Bup, mixed with other unprescribed & illicits with them. So as you can see, if the gov is still unwilling to be specific when identifying what actually people died of, how can they ever expect to stop more from dying if they refuse to even identify the problem honestly & ethically? . . . We cannot cure genetic addiction in others by torturing the disabled & elderly who need pain relief that safe & effective prescription opioids have provided for 600+ years & got us through amputations in the Civil War. Demonizing prescription opioids was the biggest mistake & most deadly one the CDC has ever made, that will be in the history books for generations to come . . . The war on drugs 50th anniversary is this week (how ironically beautiful) & you’d think we’d know better by now but for some odd reason the powers that be want Americans in the grave as fast as possible & love keeping the cartel employed with American customers & love driving the demand for them to continue spinning out deadlier & deadlier fentanyl logs. If you want to know what you can do to help addicts, it’s stop telling the government to restrict & prohibit safe prescription opioids & end the drug war & for the love of God stop torturing the disabled & give them their pain meds back & stop torturing non-addicts. It’s demonically evil what’s happening to the sick, diseased, cancer ridden, elderly, Veterans & hospice patients in America . . .

  • Tavia M says:

    People that struggle with addiction should absolutely be treated with love and respect and should have treatment available to them. I absolutely agree with that. However, people who are suffering horrific physical pain wether it be after a surgery or painful injury, or someone suffering horribly everyday from a form of chronic intractable pain, or end of life patients. All are a completely different conditions/diseases. These people are suffering a fate that is inhuman and the pain is unimaginable! I am one of those hundreds of thousands or even millions who have been abandoned by our medical communities and our government. We are automatically looked down upon and judged/labeled as addicts. We are abandoned and sent home to suffer and die either by our bodies breaking down from the pain or by us taking our own lives because we can no longer live in a body that tortures us every moment of every day. We are treated like animals and made to feel ashamed for being ill. None of us asked for this life but it’s the hand we have been dealt. Where is the outrage for our cause? Who will fight for us to be treated with the only medications that help a large majority of us? Why aren’t tax payers being told that their hard earned money is going to paying otherwise hard working people to stay at home and suffer rather than giving the right dosage of opioid pain medications so they can go work to support themselves and their families? Our pain will never be 100%, but if we can get the medications so we can take the edge off so we can live our lives, work, play with our children, exercise just something as simple as cleaning our home. The things you take for granted are the very things we can’t do. We are placed in the same category as addicts but the issues are vastly more different. Addicts take drugs to hide from the world, pain patients need the drugs to join in on life! The issues could not be any different! In fact, We are opposite! . . .

  • Stanley says:

    Group think can become a dangerous path to go down. In fact it effects what gets funded for research and what doesn’t. Constructive criticism is always beneficial if those to whom it is given, are able to put aside their egos and listen. I have been watching the group think play out in terms of “vaccine complacency” and making decisions based on incomplete data. Without titer checks, the effectiveness of the vaccines in certain populations who are prone may not be as high as those numbers touted for the 18-65 primarily Caucasian cohort for which the majority of clinical trials were done. Please do not let science be dictated by political agenda, and it’s not an easy job distilling science to lay public, especially those who may not have any scientific training. So kudos to those who do.
    I guess chalk it up to differences in interpretation based in hypothesis driven methodology, versus observational conclusions.

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