Since 2018, HHS Assistant Secretary of Health Dr. Brett Giroir has been in charge of some of the Trump administration’s largest public health initiatives, including its fight against the opioid epidemic and the goal of eliminating the HIV epidemic over the next decade. Giroir, a former medical school executive, recently spoke with Modern Healthcare reporter Steven Ross Johnson about the strategies moving forward to address public health crises as well as the future for the U.S. Public Health Service’s active duty force of uniformed health professionals. The following is an edited transcript.
MH: The opioid crisis has gone through a number of phases since its inception. It was predominately prescription drugs. Then it was heroin and now it’s fentanyl. How has the change in the epidemic’s nature influenced your approach to combating it?
Giroir: Fundamentally they’re all opioids and we need to treat them the same. We’ve got to decrease people getting dependent and addicted on them to begin with. Often that starts with prescription opioids.
The traditional pathway has been overprescribing of opioids. A person becomes dependent, then addicted as prescription opioids become much more expensive, or they try to get them on the street, then there was very highly potent, very cheap heroin. Now even fentanyl is much cheaper on the street. So there’s a progression.
We approach the whole opioid problem in a very similar way. We need to prevent it by reducing prescriptions, by dealing with some of the issues that would cause people to be on opioids themselves, to get people into treatment. Whether it’s prescription, whether it’s heroin, whether it’s fentanyl, you need medication-assisted treatment, number one.
The data from 2017 to 2018, we are reducing overall overdoses by 5.1%. Our amount of prescriptions are down by about 31%. We have at least 1.2 million people receiving medication-assisted treatment. All kinds of good things are happening across the board. Not that we’re over with this, but I think that the approach has made an important impact.
For many areas, we’re entering the fourth wave, which is methamphetamine. It is the primary drug that’s causing overdoses. I just want to foreshadow that we are very focused on methamphetamine as a fundamentally different drug, not a completely different problem.
MH: What can be done at this point? There have been restrictions on over-the-counter medicines that could be used to produce meth.
Giroir: The amount of production of methamphetamine in the U.S. is tiny. It’s really transnational cartels that are intentionally marketing meth … and meth is a highly addictive drug, much more addictive than even opioids.
It’s all of the approaches. We need more behavioral health providers. We need more prevention. We absolutely need more prevention specific to methamphetamine.
MH: Congress and the administration allocated roughly $3.3 billion in federal grants to combat the opioid crisis, but that’s set to run out. What’s the administration’s position on funding going forward?
Giroir: There is a firm commitment by the administration and by Congress to continue the support for all the programs that we have and, if anything, to expand programs to cover for issues like methamphetamine and other mental disorders that go with that.
Eventually, and we’re working on this, we need to transition from a grant-based (approach) to a sustainable base. We don’t want funding to depend on how much grant funding is available. We want to integrate this into the Medicaid and Medicare systems so we have a sustainable system that’s reliable and what you’re seeing is new models of care, like the Center for Medicare and Medicaid Innovation model to take care of mothers who may have opioid use disorder.
MH: Shifting to HIV, the administration announced in May that Gilead Sciences was donating enough doses of Truvada to treat upward of 200,000 people for the next 11 years. What is the plan to get such pre-exposure prophylaxis (PrEP) treatments to the most heavily affected populations?
Giroir: We’re working on an implementation plan now. We expect within the next two to three months to have PrEP on the street through this plan with distribution.
I can’t talk about some of the specifics, but it’s going to be a distribution method that aligns with a lot of the current methods so that it has the potential to not be stigmatizing. PrEP by mail, all the kinds of things that a normal program would have. Again, this is geared toward the uninsured.
MH: I wanted to ask about the U.S. Public Health Service. There have been proposals to streamline the active duty force. What plans do you see for any reforms?
Giroir: The administration’s position has evolved dramatically in the past 15 months from whether we should downsize the corps to how we use the corps. The surgeon general and I took it as our highest priority to do a modernization plan to understand where we’re going to be in the future, what do we need to do.
Right now we’re at about 6,400 members in the regular corps. We put a plan forward. We’ve discussed it with members of Congress and with the Office of Management and Budget. We think we need to go from 6,400 to about 7,700 to 7,800 in the regular corps and a reserve corps of 2,500. That would be much like the military reserves. Our deployment responsibilities have gone up about 40% per year. Hurricanes, natural disaster. We have Ebola looming in Africa again, so we absolutely need to have a strong corps with a reserve corps that can come in.
We are going to focus our regular corps, not that we’re abandoning other agencies, but we’re going to have a clear focus on provision of care to underserved populations.
Our framework is the Indian Health Service, which cares for about 2.1 million people; often the most underserved, often the most rural with the most chronic conditions and social determinants of health needs. They are always 30% understaffed in their clinical providers. So we feel it’s a moral obligation of the corps as well as the United States to try and do as much as we can do to supply the Indian Health Service. The other would be the Bureau of Prisons. A third is Homeland Security, and that’s both the Coast Guard as well as working on immigrant health, for example, in ICE facilities.