As Mr. W. and I sat there sizing each other up, I could feel our reserves of trust beginning to ebb. I was debating whether his pain was real or if he was trying to snooker me. He was most likely wondering whether I would believe him or if I would be biased because he was an African-American man with a history of drug use. Studies show that minorities are consistently undertreated for pain.

There were certainly a few red flags in Mr. W.’s story, but his circumstances were also entirely plausible. I asked as many questions as I had time for, but we were already running late. It could take weeks to get an appointment in a specialty pain clinic, and restarting physical therapy wasn’t easy with his insurance. In the end I had to decide whether I was more ethically comfortable denying meds to a patient in legitimate pain or inadvertently supplying an addict.

Realistically, a drug addict denied will almost always find a way to get meds, but a person with real pain truly suffers. And so despite some misgivings, I gave Mr. W. a prescription for oxycodone and scheduled another visit to discuss his pain issues in more depth.

The challenge Mr. W. presented was typical: pain that cannot be “objectively” verified; complicated circumstances that do not fit easily into a handy treatment algorithm; a shortage of pain specialists; insurance plans that cover prescriptions more readily than they cover physical therapy, acupuncture or massage; and a reimbursement system that does not prioritize thorough discussions.

Some attention is beginning to be paid to this problem. For example, New York State has created a registry for narcotic prescriptions so doctors can check for patterns of abuse. This is helpful, though the laborious mechanics of the system are a major impediment. Additionally, people who are determined to outfox the system can always fill their prescriptions in neighboring states.

Clearly, we need more pain management specialists and better insurance coverage for nonpharmacological treatments and extended doctor-patient discussions. It is also critical to address the aggressive pharmaceutical marketing that did much to create the mess we are in now.

But the vast majority of pain medication decisions take place during ordinary office visits like Mr. W.’s, within a swirl of imperfect circumstances. A solid doctor-patient alliance is a critical factor for good health. But when patients feel judged by their doctors, and doctors are exhorted to not undertreat pain and simultaneously pilloried for overprescribing pain meds, this relationship can be sabotaged. That isn’t good for anyone’s health.