The situation of my friend and colleague James Urban, M.D., (“East Greenwich doctor’s license suspended over drug sales,” news, Sept. 20) is unfortunate. I’ve known Jim for over 25 years. I trust his medical knowledge, his clinical skill and judgment and I have referred patients to him. I was not surprised to read, however, that he was willing to treat people for pain. Jim’s just the sort of doc to do that, and there aren’t too many of them out there.

Most of my colleagues stopped treating pain years ago. No one treats pain anymore. Even so-called pain clinics will not adequately treat pain. On one level it’s understandable. There are no consistent established national guidelines for pain treatment. Even if there were an established protocol it would probably fail to address the subjective nature of pain. If you’re sued for causing someone’s addiction there will be a mile-long parade of expert witnesses criticizing your work and telling the jury what you should have done. To add more confusion, there is no way to accurately assess if a patient actually has pain; there’s no test for pain. And drug addicts will tell you that everything hurts and that they’re in constant pain.

Medical literature describes studies demonstrating normal MRIs in people who report severe back pain, and abnormal MRIs in patients who report no back pain. Fibromyalgia is another can of worms. I’ve treated many fibromyalgia patients (mostly women) sent to me (I’m a psychiatrist) because their fibromyalgia pain was thought to be “all in their head.” Thalamic stroke and kidney-stone pain are two other situations where there can be excruciating pain, little benefit from even the most powerful pain medications, and little to no evidence for the pain on imaging studies like MRIs and X-rays. So what does a doc do? Do you treat the pain or not?

Many years ago, during my clinical training, I had a middle-aged female patient addicted to pain meds. The treatment team thought that either her pain was psychosomatic or that she was simply an addict. As the psychiatry intern, I was assigned to her care.

She was horrible. Always complaining. She would page me around the clock. The story was that she had become addicted to pain meds years before and now would seek admission to the hospital to have access to opiates. Her chief complaint was severe abdominal pain. We tried everything to quell it, ordered every imaginable study, tried every pain med, even PCA — patient-controlled analgesia.

At my suggestion we gave her placebo pills, trying to trick her brain into thinking that the pain had gone away. Nothing worked. She was simply addicted to pain meds, that’s all. Plus she obviously had a “personality disorder” — a diagnosis used as a flag to future treaters that she’s a pain in the butt. I was relieved when she was finally transferred to the surgical floor — for more probing and scoping studies. By then she was on a pain-med cocktail that kept her more sedated than pain-free. I remember wondering how much this one addict was costing the health-insurance pool — what a waste of money.

About one year had passed when I ran into one of the surgery residents who had taken over her care. The resident told me that she had heard that the patient had recently died but she didn’t know the details or any autopsy results. I called the attending physician and reminded him who I was and that I had treated his patient for a time. He remembered the patient well. Cause of death: pancreatic cancer. All the imaging and lab studies had been negative. Her pain had been real. We, I, never believed her.

The pain in cancer of the pancreas is one of the most horrible imaginable. The pancreatic enzymes back up and the person suffers the pain of “autodigestion” — the powerful enzymes dissolve anything they contact, causing the patient to digest his own organs. It’s agonizing. I learned an important lesson.

Again, the treatment of pain is a huge problem. I read that the Drug Enforcement Administration at one time had a pain treatment protocol on its Web site, but when a doc charged with a violation used the DEA’s own protocol in his defense, the protocol was removed. It’s safer for docs to just avoid pain patients. I remember one colleague who said to me: “Yeah, I see the bones rubbing together on the MRI and I know he could use something for pain, but I’m not going to become the ‘go-to guy’ for Vicodin.”

Certainly you can send all pain patients to the methadone clinic, but for most people methadone is more addicting than heroin. It can be sedating, cause weight gain and requires a daily trek to the clinic for dosing. Suboxone (Buprenorphine) can also be used to treat pain but there are inexplicable and indefensible federal limitations on access to it.

Opiate pain medications are a defective product. They help pain but accelerate the aging process and put patients at risk for a lifetime of addiction. There is no “safe” way to prescribe them. All of us have followed the addiction problems of celebrities and politicians. Unfortunately, the opiates remain the only reliable balm for severe physical pain.

Dr. Urban was a captain in the U.S. Army during the Vietnam War. Together, we ran the gauntlet of Italian medical school at the University of Rome, where only 12 percent of our freshman class graduated. I know what he has survived, I know what he sacrificed to become a physician.

Regarding Rhode Island Atty. Gen. Patrick Lynch’s charge that he is a “threat to the health, welfare, and safety of the public,” Dr. Urban, as far as I know, never worked as a lobbyist for the tobacco industry.