Page 5 - Volume 70 Number 2
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President’s Message
By Joseph Nnodim, MD
Confronting Substance Abuse and Sexual Abuse
 Two issues that have dominated public discourse on health in recent months are the opioid crisis and the serial sexual molestation of young athletes. One feature these issues have in common is abuse – the first, substance abuse by patients, the second, abuse of power by a physician – both having profound consequences for our profession.
The medical use of opioids in the United States dates back to the Civil War in the early 1860’s. In 1914, they became controlled substances under the Harrison Narcotics Act and thereafter, could be obtained only with a doctor’s prescription. In the decade of the 1990’s the American Pain Society reached the conclusion that pain was widely under-assessed and under-treated in US hospitals. They launched an initiative to raise clinician awareness of the importance of pain assessment. Patients’ self-reporting was considered to be the most reliable indicator of pain and the need to take action whenever such a report was made, was strongly recommended. The phrase “pain as the 5th vital sign” was coined and the Veterans Health Administration was sufficiently persuaded to include it in their national pain management strategy. In 2000, as part of its pain assessment and management standards, the Joint Commission on Accreditation of Healthcare Organiza- tion (JCAHO), stressed the patient’s right to appropriate assessment and management of pain. A brief letter, which had been published 2 decades earlier in the
New England Journal of Medicine (1980; 302\[2\]:123) suggesting that the development of addiction was rare in patients treated with narcotics, was cited widely as evidence of opioid safety. Viewpoints such as these set the stage for the crisis that was to follow.
The prescription of opioids escalated steadily nationwide in the decade of the 1990’s, from 112 million prescriptions in 1992 to a peak of 282 million in 2012. About 11.5 million people aged 12 years and older misused prescription opioids in 2016, according to the Substance Abuse and Mental Health Services Admin- istration. Prescription opioids have also served as a gateway to more accessible and less expensive street opioids like heroin. The public health impact has been staggering. In our county, Washtenaw, fatalities from opioid overdose rose steadily in the first half of this decade, from 29 in 2011, to 65 in 2014. Although a 25%
decline in deaths
was recorded in 2015,
the numbers remain
unacceptably high.
As of October in 2017,
54 persons had died
from opioid overdose
during that calendar
year, often from
illegal synthetic opioids obtained on the black market.
What is being done to combat this epidemic? In 2013, the Washtenaw Health Initiative, a consortium of over
80 organizations in the county, including the big health systems (Michigan Medicine, St. Joseph Mercy and Veterans Affairs), community services and law enforce- ment, launched the Opioid Project. This bold endeavor is energetically raising awareness of the opioid crisis and promoting both preventive measures and interventions to support persons struggling with addiction and chronic pain. \[Read more about what is being done at the state level in this issue of the Bulletin.\]
The other topical health issue is the abuse of over
200 young women patients by their physician over two decades. Any relationship in which a significant power disparity exists between the persons involved is fraught with the potential of abuse. Highly publicized analogous abusive relationships have come to light in the motion picture industry as well as the broadcast media. The case of the Michigan physician is particularly concerning because of his violation of the doctor-patient compact and the ages and its effects on the victims.
Among the privileged professional relationships which society has granted special protections, the doctor- patient relationship is unique. Priests cater to the
spiritual needs of the penitent while attorneys and their clients transact corporal matters. The doctor-patient relationship however encompasses both realms, body and soul. Hence, the scope of damage in the event of misconduct is much broader. As has been noted, it is a fundamentally asymmetrical relationship, given the doctor’s wealth of specialized knowledge for dealing
with illness which the patient often lacks. Even with well-informed and independent-minded persons, illness is individuating and as patients, the charisma or person- ality of the doctor operates in ways, often subtle, that >>
Volume 70 • Number 2 Washtenaw County Medical Society BULLETIN 5

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