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Yesterday the daughter of a patient said that the suffering in the world is out of control.

I looked at her.

She revised it. "We are more aware of the suffering."

I said, "I think some people in the United States have the mistaken idea that all pain can be treated and that we ought to be able to live pain free."

Suffering and addiction are the themes this month and last. They circle around me, swirling and dancing.

A pain clinic lost prescribing privileges four days before Christmas in town, releasing more than two hundred patients on methadone and buprenorphine and narcotics into the local medical community. The police in flack jackets went into the clinic and came out with computers and paper and no one knows whether it's justified or not. People have told me that patients lay on the floor and wept as they went in to withdrawal. And it is the Medicaid Billing Fraud team that lead the closure, not the DEA.

Chronic pain and addiction go hand in hand. I run across people who say, "I can't be addicted to narcotics, because I'm taking them for pain." Anyone who takes narcotics: codeine, vicoden, percoset, percodan, oxycodone, hydrocodone, oxycontin, methadone, anyone can become addicted. The perception is that it is the people who buy it on the street, who party with it, who are trying to get high, they are the ones who get addicted. Some of them do too, of course, but treating chronic non-cancerous pain with narcotics is difficult. I resist using long term narcotics on people with non-cancerous chronic pain for two reasons: I almost NEVER see it control the pain and I see people get addicted. Narcotic dependence: there is physical dependence and there is emotional dependence.

I think there is a huge myth perpetuated by pharmaceutical companies and with the medical community culpable: Doctors Can Control Your Pain. If you have chronic pain, see your doctor. Doctors are frightened, honestly, because they are getting sued for inadequately controlling someone's pain after the someone dies, sued by the family. AND we are getting arrested or raided or closed down for attempting to control pain. Don't give out too many narcotics or too few. Good luck figuring out the right amount.

But the drug companies exist to sell drugs and make money, after all. Isn't that the American Dream? To make the big bucks and retire? The pharmaceutical companies are deleriously happy that we have gone from treating end stage cancer patients with narcotics to giving them out like candy to anyone who says that they have pain. Treat pain, treat pain, treat pain. But not too much. Or else.

Why is chronic pain so difficult to manage? Pain has three elements. One is the nocioceptive, cut your leg, stubbed your toe, broken leg pain. Easy to treat. Narcotics work. The second is nerve pain, burning. Sciatic pain or the pain after shingles. This is called neuropathic pain. The third is emotional pain. The third is the neglected one.

When I have a new chronic pain patient, I talk about all three. I say that we can't measure what proportion of the pain is nerve, nocioceptive or emotional. I can't tell what proportion of the pain is emotional. A pain clinic physician recently called it "existential suffering". Nice term, but I think emotional pain is clear enough. We approach that through counseling, through medicines, through groups, through church, through support, there are multiple pathways. But this takes time.

And time is what primary care doctors no longer have. Remember that I am no longer in the hospital clinics in my small town because I fought for more time with patients. They cut us to 20 minutes. I have a clinic of my own now, with a slashed budget and contracted only with medicare so that I can schedule an hour with a new person over age 65 and 45 minutes with anyone under 65. Though I want an hour with the flood of chronic pain and addiction patients that I've gotten in the last two weeks. They are complex, in shock because of the sudden closure of their clinic, I'm not a pain specialist, I'm not their doctor, they are angry/grieving/upset. Me too.

With a 20 minute visit, is it easier to discuss emotional pain and approaches to it, or is it easier to write a prescription for vicoden or oxycontin? Is it easier to tease out the strands of someone's life and the suffering they have endured, or to give them drugs? Oh, it's so much easier to write the prescription. And it breaks my heart, the vice grip that the primary care doctors are in. And even more, the way that the patients are being treated.

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