Dr. Willem J. Nel prodded his patient's lower back, making her wince.
"I'm sorry, sweetheart," he said.
On good days, with lots of pain medications, Kathleen Spearance's pain is a 7 out of 10 - the result of scoliosis and her efforts as a transport nurse to stop an obese patient from rolling off the bed.
"My spine is not collapsing anymore, but my pain level ..."
"Is about the same?" he asked.
"Worse," she said. "I need more meds to keep my pain level what it was. I want to get off the drugs, but I can feel this. On my worst days it's not working. I'm at the plateau. I don't want to go up though."
As a board-certified pain medicine doctor, Nel makes critical decisions almost every day about how to help people suffering with severe pain. It's a complex job that can make the difference between someone feeling a whole lot better or spiraling into addiction.
But lately, images of out-of-control Florida pain clinics with lines of addicts - many of them from out of state - have left a stain on this pain business.
Nel, 44, feels the backlash and it makes him angry. Often he's trying to help someone like Spearance, who is suffering but doesn't want to be on drugs.
"We'll find other ways," he told her.
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Recently, police and local governments have attempted to crack down on the dozens of "pill mills" contributing to overdoses and deaths across the region. It is estimated there are more than 100 pain management clinics in Pinellas and Hillsborough counties. Many of them attract people who want quick and easy access to powerful narcotics like oxycodone and Xanax.
Many of these places are themselves a serious pain for doctors like Nel, who has a board certification in anesthesiology and 12 years' experience in pain medicine. While other doctors hand out oxycodone like Chiclets, he says, he's trying to offer responsible and ethical medical treatment to people with a real need. But it's hard for the public to tell the difference.
Pain medicine is a relatively new medical field, so new that the American Board of Medical Specialties recognizes it only as a subspecialty of a handful of other medical specialties. Nel is one of 1,851 doctors in the United States who completed a fellowship and became certified in pain medicine by the Board of Anesthesiology.
Anesthesiologists have traditionally formed the backbone of pain relief medicine. Anesthesiologist John J. Bonica, who wrestled as the Masked Marvel to put himself through medical school, wrote The Management of Pain in 1953.
Today there are pain management centers at many major hospitals and universities, and reputable doctors in clinics across the country.
"Pain medicine is not drug dealership," said Dr. Michel Y. Dubois, professor of anesthesiology at NYU School of Medicine. "It requires complex knowledge of a lot of different techniques. It's far more than just medications."
Recently, the Sheriff's Office showed up at Nel's clinic door, asking him to register his pain clinic. To him, it was offensive.
"I'm a doctor and I'm highly trained," Nel said. "But there's a stigma that goes with this that's out of control."
Two weeks ago, an 85-year-old woman struggling with back problems canceled her first appointment because she didn't want to become addicted.
But Nel points out that not everyone who takes pain medication will get addicted. The majority, he says, won't.
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Spend a day in Nel's medical practice and you will see lots of pain. Some patients can barely walk or lift their arms. Others have rods inside their backs, their necks. Surgery scars line their spines, their knees.
Nel deals with each patient differently.
He set up a 64-year-old pilot whose vertebrae were out of alignment with an anti-inflammatory injection. Pilots aren't allowed to take opioid drugs like oxycodone.
He refilled prescriptions for a 59-year-old woman with two rods fusing her head to her neck and sent her to acupuncture and massage therapy to relieve tense muscles.
He told a 67-year-old house cleaner who couldn't sleep more than two hours because of pain in her pelvis to take a small dose of morphine at night.
Many of his patients expressed concern about taking hard-core prescription drugs. They were struggling to wean themselves.
"I'm trying my best to take Tylenol instead, but when the pain gets too bad, I have to take that pill," Kysha Mordica, 36, told Nel during her monthly visit. She's taking oxycodone he prescribed for nerve damage following surgery to remove an abscess on her lung. "I know I'm not crazy."
Kathleen Spearance, 53, the former nurse who has had back surgery, told him she felt the same anxiety.
She wants to be on fewer prescription drugs - not more - and had hoped back surgery would help. But so far it has not eased her pain. She's still on a Fentanyl narcotic pain patch, a semisynthetic version of morphine, a muscle relaxer and an antidepressant pain reliever.
"I'm not going up," she told Nel.
Nel has options for patients who have plateaued on their pills and are still hurting. Sometimes, instead of increasing a patient's dose of an addictive controlled substance, he'll switch to a new medication. Then when that medicine starts to have less effect, he'll go back to the first medicine.
In Spearance's case, he wants to give her anti-inflammatory injections to block the nerves. But she had an allergic reaction to one type of steroid. So he referred her to an allergist to see if there were other steroids she could take.
"Let's do the allergy testing and get you in next week," he said.
"I'm not giving up," she said.
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Michael F. Sunich stepped into Nel's office with the file of a man struggling with neck pain.
Nel hired Sunich, a licensed psychologist and addiction specialist, a few months ago to screen every patient. It's Nel's effort to make sure he does not contribute to anyone's addiction, and to help patients who have psychological needs in addition to their pain needs.
The man had been Nel's patient since a neck surgery two years before. But during a routine urine test, Nel had found a prescription drug he had never prescribed. So Sunich had interviewed the man that morning.
"He's got a long history of drug addiction," said Sunich, 56, sitting in front of Nel's desk. "He was in Narcotics Anonymous for 18 years. He doesn't go to meetings anymore. He claims he's been abstinent."
Sunich explained that he had told the man that his former heroin addiction was a far cry from being sober. But taking a relative's meds, as he had done, was another step closer to going back to his addiction. The man needed to take action.
"He said he'd go to a Narcotics Anonymous meeting again," Sunich said.
Nel was surprised. But it all made sense. The patient had been asking for more and more meds.
"The question now is what to do with him," he said.
Addiction is a fine line, which Nel and Sunich navigate every day. Some patients abuse the drugs by taking too many or selling them, but without getting addicted. A number, like Kathleen Spearance, are dependent but not addicted.
The drugs create cellular changes in everyone's body, so stopping it creates withdrawal symptoms. For those who don't have "addictive brains," this is just a matter of tapering off the drug until the body gets used to not having it.
But for those with a propensity toward addiction - about 10 to 15 percent of the population - the brain craves the euphoria. The dopamine reward that comes with taking the drug becomes necessary for survival.
Once the drug wears off, feelings return - guilt, shame, remorse and anger. Alarms go off and the addict brain goes into survival mode again, wanting to eliminate the pain. And since the drugs don't have the same effect as time goes on, people with addiction tendencies take more and more to capture that euphoric feeling.
"If any patient has an addiction issue, I have a treatment plan mapped out in my head, but addiction with pain is a very different animal," Sunich said. "There is nothing on the list that guides us: these are the best practices. You're going down a footpath here, and you know there's a trail but only rabbits have been on it ... sometimes it's more art than science."
Nel nodded, looking through the man's file. He wasn't going to turn him away. But he felt responsible for making sure the man didn't cave in to his former addiction.
"We're going to have to re-evaluate what we're doing here," he said.
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Lorraine Jackson, 39, held her right arm upright in front of her, claw-like. The sleeve of her black velvet jumpsuit was pulled above the elbow.
"I'm not happy," she told Nel as he walked briskly in to the patient room with her file. "I felt it coming from my eyeball."
In 2005, a large tree limb fell on Jackson, striking her head and piercing her arm. The injuries healed but she acquired an unusual nerve condition in her arm known as Reflex Sympathetic Dystrophy Syndrome that causes severe burning pain, chills and numbness. Goosebumps ran to her elbow. Any light touch made her flinch.
"It's so bad today, that just the sound of my voice is making it hurt," Jackson said.
Jackson, once an architect, refuses to take pain medications. But she will accept a nerve block, an injection of local anesthetic.
"So you're going to inject me tomorrow right?" she asked.
Nel nodded, writing in her file.
"Oh thank goodness," she said. "What time?"
Times researcher Shirl Kennedy contributed to this report. Leonora LaPeter Anton can be reached at email@example.com or (727) 893-8640.