I hadn’t seen Larry in a dozen years when he reappeared in my office a few months ago, grinning. We were both grinning. I always liked Larry, even though he was a bit of a hustler, a little erratic in his appointments, a persistent dabbler in a variety of illegal substances. But he was always careful to avoid the hard stuff; he said he had a bad problem as a teenager and was going to stay out of trouble.
It was to stay out of trouble that he left town all those years ago, and now he was back, grayer and thinner but still smiling. Then he pulled out a list of the medications he needed, and we both stopped smiling.
According to Larry’s list, he was now taking giant quantities of one of the most addictive painkillers around, an immensely popular black-market drug most doctors automatically avoid prescribing except under the most exceptional circumstances.
“I got a bad back now, Doc,” Larry said.
Doctors hate pain. Let me count the ways. We hate it because we are (mostly) kindhearted and hate to see people suffer. We hate it because it is invisible, cannot be measured or monitored, and varies wildly and unpredictably from person to person. We hate it because it can drag us closer to the perilous zones of illegal practice than any other complaint.
And we hate it most of all because unless we specifically seek out training in how to manage pain, we get virtually none at all, and wind up flying over all kinds of scary territory absolutely solo, without a map or a net.
The events of the last few decades haven’t helped much. First came a consumer-driven “pain power” movement — justified, for the most part — pointing out that pain was wildly undertreated by most doctors. And then, more recently, came the new statistics on the widespread abuse of prescription narcotics, which now saturate street corner markets everywhere and cause more overdose fatalities than heroin and cocaine combined.
In other words, we are now cautioned in the strongest possible terms against giving too little medication and too much, being too free and too parsimonious, underprescribing to the right people and overprescribing to the wrong. Most official guidelines and policy statements, even fuller than usual of vacuous general principles, aren’t of much help in figuring how to do any of this.