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.
One of the most accurate, articulate and heartfelt reflections on the situation was written a few years ago in Archives of Internal Medicine by Dr. Mitchell Katz, who now directs the Los Angeles County health department. Dr. Katz described his slow disillusionment with the standard approach to pain control, which involves escalating from nonnarcotic to narcotic medication, then prescribing as much as needed to eradicate the pain, while deploying measures like written contracts, pill counts and urine tests to make sure the patient is taking it all as prescribed.
It is awfully hard to take that road without turning into the patient's parole officer. And so, Dr. Katz suggested, how about a regulatory body establishing a reasonable cap for narcotic dosing, at least for people without malignant diseases who are likely to be taking them long-term? Also, how about formally acknowledging that sometimes pain cannot be entirely eradicated? "Leaning how to cope with pain can be more empowering for patients than trying to find a pill to completely eliminate it," he wrote.
Clearly Larry's last doctor wasn't buying into these sentiments, given the quantities of medication Larry was asking for — assuming there actually was a previous doctor in Larry's life. All I had for evidence was a list, in Larry's handwriting. The pills themselves, the bottles? "They got stolen off me on the bus here," Larry said.
When was that?
"Last month," Larry said.
Ultimately, all careful nomograms fall aside in the face of the particular patient. I was lucky enough to know Larry pretty well, although in some ways that only made things more difficult. I knew he was a decent and intelligent guy, with a pretty sophisticated understanding of his own problems and a hard time keeping straight. I also knew he was clearly walking with the careful "don't touch me" gait of someone with a really bad back.
And Larry, of course, knew me well, too — well enough not to be surprised when I sent him off with a sheaf of referrals to evaluate his back, a weaker, nonnarcotic pain reliever, and not a single one of the requested pills. He just smiled and said, "I knew you wouldn't give them to me."
These decisions are always harder than hard; you have nothing but instinct and experience to guide you, and you never know if you've done the right thing. I think about Larry periodically, but I haven't seen him since.
