Mr. Esposito looked defeated. Despite being in his early 40s, he hobbled into the exam room with his back hunched, wobbling slightly and clutching a cane.

Sitting down was difficult for him — a prolonged negotiation with the small chair across from mine. His eyelids sagged, his shoulders hunched. His body was speaking to me almost directly: I am in pain.

I asked him how he was doing, but I already knew. He was hurting. A football player from junior high onward, he'd developed arthritis in his knees, hips and lower back. He had back surgery a few years ago for spinal stenosis, but it didn't help. His body was showing signs of wear and tear that would be extreme for someone 30 years his senior.

This was only my second encounter with Mr. Esposito. I saw him three months before, and I recommended our standard approach to arthritis — weight loss, physical therapy, capsaicin cream and over-the-counter anti-inflammatories like Tylenol and Naproxen.

"Have you been to physical therapy?" I asked.

"Yeah, I went once. They want me to go weekly. But my job won't let me take off anymore. My boss is already mad enough that I'm here now."

I remembered our last visit, when he told me that his boss wouldn't allow him to work a desk job, saying that he had hired him only for the physical labor of moving crates of milk from the truck to the loading dock.

"Your boss sounds like a piece of garbage," I said.

Mr. Esposito briefly cracked a smile. "Look," he explained, "better this job than none at all. Job market's tough right now."

"I'd be happy to write you a doctor's exemption, some kind of paper saying you can't do manual labor," I offered.

He said he'd take it, but that his boss didn't really care about stuff like that. If you could do the work, you were paid. If you couldn't, you were fired, and they were on to the next laborer.

"There's really only one thing I've ever taken that's worked. I went to an ER one time when it got real bad. I got this med — Norcan? Norcal? — something like that."

Finally, we were here. The place where any chronic pain conversation inevitably turns. Opioids. The med he was trying to recall was Norco, a mix of acetaminophen (Tylenol) and hydrocodone, a powerful oral opiate.

Our country has a major opiate addiction. The IMS National Prescription Audit puts it in daily terms: Today, 650,000 opioid prescriptions will be filled in pharmacies across America. Today, 3,900 people will try nonmedical opiates for the first time. An additional 2,500 will try heroin for the first time, and 80 of them will die from overdose.

Opiates don't play nice with other meds. The relief they provide is exponentially more powerful and immediate than other analgesics. But it is temporary. Opiate withdrawal is a brutal combination of insomnia, vomiting, diarrhea and continuous searing pain. It is nearly impossible to wean someone off of them once they've started. Opiates are all they want. Paradoxically, research suggests that long-term opiate use actually sensitizes the nociceptive (pain-sensing) neurons in the body, worsening the problem that was the reason they started the drug in the first place.

"Norco," I said.

"That's the one," he said.

"Let me tell you a story."

And I tell him about the first patient I saw who was on so-called "replacement therapy" for opioid addiction, methadone. He was a vet, and he had been stationed on an aircraft carrier during his service. There was an accident on the main deck, and a steel cable used for launching fighter jets snapped and whipped him in the leg, instantly shattering his femur.

Three surgeries and two years of recovery later, he could walk. But he required high doses of opiates to keep his pain at bay. He became addicted to oxycodone, then heroin. He tried to quit, but couldn't, and after long struggles with rehab, ended up on methadone. A dangerous addiction traded for a less dangerous addiction.

I asked him what his life was like now compared to before. He almost started crying. "If I knew how bad it would be, the needing it, the misery, the vomiting — I wouldn't have touched it." He practically spat the words out. "Wouldn't have even smelled it."

Opiates put doctors in a tough spot. Mr. Esposito was hurting. But he was also a model patient. He did exactly what I told him to do. He has an impossible job situation, and a medical condition that makes him wince with each step. I want to make his pain go away. He deserves to be pain-free. But opiates aren't the answer.

What is the answer? I don't know, exactly, but I think it has to start with a respect and the understanding that powerfully addictive medications like opiates can warp people, changing them permanently.

Homer wrote in "The Odyssey" about an island filled with a mysterious, addictive plant called Lotus. Ulysses lands his men on the island, but is horrified by what he discovers: "Those who ate of it left off caring about home and did not even want to go back and say what had happened to them, but were for staying and munching lotus with the Lotus-eaters without thinking further of their return."

If doctors ever seem stingy with pain meds, it's because we have seen the full arc of the story. Some people make it off the island of the Lotus-eaters. But some never do.

Benjamin Gold, MD (@bengoldmd), is a third-year internal medicine resident at Baylor College of Medicine. He also is a musician and blogs about the extraordinary circumstances his patients face. Names, ages, dates and other details have been changed for patient confidentiality.

Bookmark Gray Matters. Those who eat of it leave off caring about home and do not even want to go back and say what happened to them.

