PROVIDENCE – It is not possible to think coherently about drug and alcohol use or drug and alcohol overdose death without thinking about pain and suffering. Drugs and alcohol have some socially acceptable uses, which include the treatment of pain.

But we don’t understand how to treat pain effectively, so we may well be contributing to drug and alcohol abuse because of that ineffectiveness, creating dependence and addiction by over treating, and driving some people to the black market by ineffective or failed treatment.

If we are going to successfully reduce drug and alcohol overuse, we need to find a better way to understand, measure, and treat pain. Specifically, we need to fund and maintain a network of multidisciplinary pain treatment centers, so we can use our best science and medical skills to find the solution to a complex medical and social problem.

Pain is an intense noxious biochemical sensation that calls the attention of an organism to a time, a place and an event, and causes that organism to change its behavior, avoiding some stimuli, or changing their social interaction.

Suffering is the subjective experience of discomfort. It’s how a person deals with discomfort, pain, or unhappiness in the context of ego, intellect, and self. Simply put, pain is the sensation; suffering is the meaning of that sensation to the person.

Even when pain is tolerable, the fear, loneliness, isolation, self-hate, disappointment, estrangement, and bitterness that sometimes exist alongside the pain often consume the emotional energy needed to tolerate the pain.

The challenge is for us to relieve pain at the same time as we recognize and address suffering by attending to human beings and their emotional needs.

Helping people with long-lasting pain
But primary care and other physicians often aren’t effective at helping people with significant or long-lasting pain, or with helping the person with deep or intense suffering who is also in pain because we just don’t have the expertise or the time in a 10- or 15-minute office visit to tease the two apart.

Nevertheless, it is the job of health professionals to blunt, control or treat pain whenever and wherever possible. Drugs and alcohol do that reproducibly, but drugs and alcohol are blunt instruments in the treatment of pain.

While drugs might reduce pain in the short run, they often impact alertness and consciousness. The best evidence suggests that opiate pain medications used chronically stop working before long, or even make people more sensitive to their pain over time, so the long-term use of opiates creates dependence and addiction but not relief from pain.

And there are other ways to treat pain and suffering beside drugs – acupuncture, counseling, group therapy, physical therapy, and massage – which may be as or more effective than drugs are, if we could [choose] when and how to employ those modalities.

All this is even more confusing to health professionals, because patients’ reports of pain – which are usually some part pain and some part suffering – are ultimately subjective.

I have to take your report of pain at face value. I have no objective way to measure it and no way to compare your pain to anyone else’s pain. I can only rely on what you tell me. [Although we do use some observational tricks to validate your truthfulness. If you tell me your back hurts and you can’t walk, and then I see you rise out of a wheel chair and walk briskly across the street after leaving the exam room, I may question your truthfulness.]

So no doctor can tell how much pain you are really in, or the extent to which our medications are the best and most reliable way to treat your pain. Truth be told, it’s a lot of guesswork, a lot of trial and error, and most of us only know a little about how to use opiates, which for many of us are our single most effective option when we approach the treatment of pain.

Marketing has influenced choices about how to treat pain
To make all this even more confusing, it is worth noting that marketing by pharmaceutical companies influenced clinicians choices about how to treat pain. Pharma urged physicians to use pain medications more liberally once long-acting pain medications were developed and could be patented.

Then, an important hospital and medical practice oversight organization called the Joint Commission started judging clinicians and hospitals on how well we treated pain. So while no clinician can ever tell how much pain you are in, many clinicians were being pushed by marketing and by the oversight process to prescribe more.

And so the amount of opiates being prescribed jumped by a factor of 10 in a few years, and many more people became dependent or addicted to prescription opiates.

Adjusting pain meds can be tricky
Adjusting pain medicine is also tricky and time confusing, and too few of us have the expertise to do it well. Break your leg today and you need a strong pain medicine, but usually only for a few days. How much you need and how long you need it is pretty variable, so many clinicians give you a handful of medicine, enough for a month, because we know we are hard to get on the phone if you run out.

But that means there is no one to talk to if you are ready to reduce the medicine, and no one to help give you ideas about how and when to use less, no one telling you the other things you can do to control the pain, and no one is right there in case the medication isn’t working.

At the same time, clinicians aren’t good at detecting people who fake or accentuate pain in order to get drugs to sell or use to satisfy an addiction. There are too many people who are dependent on pain medicine, and have become quite good at seeing different doctors and telling stories that are usually effective at getting doctors to prescribe opiates, whether it be for personal use or to sell.

Few doctors are as good as we’d like to think at telling apart the person whose pain is “real” from the person whose pain is misrepresented in the service of what health professionals call “secondary gain.” But the medication we prescribe to those people unwittingly adds to the available supply on the street, feeding the dependency and addiction of those with substance use disorder.

If you are a person who is out to dupe doctors in this way, there is no penalty for trying. It isn’t clearly illegal to try to get opiates in this way, and there is no mechanism to catch and try you. If you are in the prescription drug selling business, you’ll try every prescriber out there, until you find a few who respond to your pitch. And the return on investment is huge. The street value of one prescription of say, 90 pills, is something like $7,200.

Multidisciplinary chronic pain centers
Some addiction results from an inadequate response to pain and suffering, and some opiate supply results from physicians’ inability to tell whose pain is real and to recognize substance abuse disorder when people claim to be in pain. Is there a better way for us to help people in pain?

A system of publicly funded chronic multidisciplinary chronic pain centers would be a much more effective – and affordable – approach.

If we had such a system – perhaps one for every 100,000 people – primary care physicians would have a place to send people with chronic pain, so the pain could be properly evaluated and treated, using as little opiate as necessary.

If we had such a system, people who had to be on pain medicine for short-term problems like broken bones or back pain could be supported and coached, and weaned off opiates as quickly as possible.

People with chronic pain could get a full evaluation, and receive a range of other treatments beyond opiates, so their pain and their suffering could be best addressed.

People with complaints of pain who currently doctor shop to obtain medication fraudulently could have their substance abuse disorder treated instead of fueled.

And, we’d have a place that could help people with the pain or terminal illness, many of whom benefit from opiates, but need skilled prescribers so that their pain is effectively controlled with minimal impact on their ability to think and feel.

There are many causes of our drug and alcohol problem, and better pain management isn’t the only solution. But it is one of a number of strategies that will be necessary. Though expensive, it’s a fraction of the cost of the problem itself in dollars, heartbreak, and human lives.

Dr. Michael Fine served as the director of the R.I. Department of Health from 2011 to 2015. He is a family physician.