BRIDGEPORT, W.Va. — The doctors wanted to talk about illness, but the patients — often miners, waitresses, tree cutters and others whose jobs were punishingly physical — wanted to talk only about how much they hurt. They kept pleading for opioids like Vicodin and Percocet, the potent drugs that can help chronic pain, but have fueled an epidemic of addiction and deadly overdoses.
"We needed to talk about congestive heart failure or diabetes or out-of-control hypertension," said Dr. Sarah Chouinard, the chief medical officer at Community Care of West Virginia, which runs primary care clinics across a big rural chunk of this state. "But we struggled over the course of a visit to get patients to focus on any of those."
Worse, she said, some of the organization's doctors were prescribing too many opioids, often to people they had grown up with in the small towns where they practiced and whom they were reluctant to deny. So four years ago, Community Care tried a new approach. It hired an anesthesiologist to treat chronic pain, relieving its primary care doctors and nurse practitioners of their thorniest burden and letting them concentrate on conditions they feel more comfortable treating.
Since then, more than 3,000 of Community Care's 35,000 patients have seen the anesthesiologist, Dr. Denzil Hawkinberry, for pain management, while continuing to see their primary care providers for other health problems. Chouinard said Community Care was doing a better job of keeping them well overall, while letting Hawkinberry make all the decisions about who should be on opioid painkillers — a role that requires not only expertise, but endless vigilance.
"I'm part FBI investigator, part CIA interrogator, part drill sergeant, part cheerleader," said Hawkinberry, who is also an amateur mountain climber.
Evidence that the musician Prince had become dependent on pain pills he took for hip problems before his recent death suggests just how hard it can be, even for people with access to the best doctors, to safely control chronic pain. Community Care is trying to do so for a disproportionately poor population, in a state that has been ground zero for opioid abuse from the very beginning of what has become a national epidemic.
Now, the difficult work of addressing the nation's overreliance on opioids, while also treating debilitating pain, is playing out on a patient-by-patient basis, including in a patchwork of experiments like this one. About 70 percent of the 1,200 patients currently in Community Care's pain management program receive opioids as part of their treatment, which may also include non-narcotic drugs, physical therapy, injections and appointments with a psychologist.
Many had already been on opioids "for many years before they met me," Hawkinberry said, adding that his goal is to get them on lower doses, and to try other ways of managing their pain.
Rigorous screening helps weed out people who are looking to abuse painkillers, Chouinard said. Patients who are prescribed opioids have to submit urine samples at each monthly appointment and at other random times, and to bring their pills to every visit to be counted. About 500 have been kicked out of the program for violations since it started in 2012.
In addition, Community Care's pain management clinic is closely monitored by the state as one of six licensed to operate under a 2012 law meant to cut down on pill mills.
The organization's primary care providers talk frequently with Hawkinberry about the patients they share with him. Because they use the same electronic medical record system, they can keep close tabs on how their patients' pain is being treated — and he on how their other health problems, like high blood pressure, are being addressed.
"We can even instant-message each other, and we do that a lot," said Dr. Kimberly Becher, a primary care doctor at Community Care's clinic in Clay, a town of 500.
In the past, Community Care's doctors would sometimes send patients to outside pain specialists, which Becher said yielded poor results because of a lack of communication.
The close contact between the in-house pain specialist and the primary care staff has especially helped complicated patients like Frances Key, who was struggling to control her diabetes and high blood pressure when she started seeing Hawkinberry three years ago. Addressing her back pain with physical therapy and hydrocodone, typically taking one low-dose pill a day, has helped her lose 50 pounds and manage her other chronic conditions.
"I was a mess when I first came — I hurt all the time," said Key, who injured her back lifting a deep fryer at her job in a deli. "I can go for a walk now; I can play with my grandkids."
One day last month, Hawkinberry saw four new patients and prescribed opioids to one: a carpenter with a congenital hand deformity that had become more painful, keeping him out of work.
He thought hard on the carpenter's case, which was complicated by stomach ulcers that made him a bad candidate for nonsteroidal anti-inflammatory drugs like ibuprofen, which new guidelines from the Centers for Disease Control recommend trying before opioids.
"What happened here?" he asked the man, studying marks on the inside of his forearm.
The patient told him they were from donating plasma, which brought him extra income.
"No history of I.V. drugs?" Hawkinberry continued, standing close and looking the man in the eye.
"No, never."
"Never?"
"Never."
The patient who allowed a reporter to sit in on the exchange would give only his first name, Frank, because he said he wanted to protect his privacy.
"I don't like to be stereotyped like everybody else," he said. "I don't want to be looked at at that level, when I am a legit citizen."
Still, he added, "I've never seen an area gone on pills of this scale, ever in my whole life."
Hawkinberry prescribed the patient a low dose of hydrocodone, 5 milligrams, three times a day until he returned in a month — "a therapeutic trial," he said, to help control the patient's pain while he started physical therapy.
"These are not decisions that I make lightly," Hawkinberry said afterward. "I fret over them; I pore over the risks and the benefits and try to really analyze, both objectively and subjectively, whether or not it's a good idea."
Chouinard said that in addition to improving patient safety, the program had helped her recruit new doctors and nurse practitioners.
"I have family practice docs coming out of residency programs call me and say, 'I've heard your health centers don't require us to manage chronic pain — can I talk to you?'" she said.
If the program has a downside, she said, it is the challenge of replicating it at other community health centers around the country. Community Care, which initially paid for the program with a grant and then lost money on it for a few years, has tried unsuccessfully to hire a second pain specialist as it has grown. Instead, it has relied on four physician assistants who work with Hawkinberry.
"If I'm an anesthesiologist, guess what I'm doing? I'm putting people to sleep in the hospital for $400,000 a year," Chouinard said. "This is mission-minded work."
Nor is it clear how much programs like this can help stamp out opioid addiction. West Virginia still has one of the highest rates of drug overdose deaths in the nation, and while deaths caused by prescription opioids are decreasing, those caused by heroin and fentanyl are climbing. One of Chouinard's concerns is that people kicked out of Community Care's pain program for failing urine screens or pills counts could turn to heroin.
Dr. Carl Sullivan III, director of addiction medicine at West Virginia University, said that Hawkinberry was "one of very few people I could trust to do chronic pain right." But he said the field of pain management in West Virginia remained "seriously undermanned."
The university's health system, WVU Medicine, is planning to provide more alternative pain treatments throughout the state, but Dr. Richard Vaglienti, its director of outpatient pain services, said it would take several years to put in place.
Given the high demand for Community Care's program, patients often have to wait up to six months for their first pain appointment. The hourlong evaluation starts with a urine drug test, a physical exam, a battery of questions to assess the patient's psychological history and risk of addiction, and a check of the state's prescription-monitoring database to see whether the patient has been prescribed opioids in the past — a check Hawkinberry repeats at every follow-up appointment.
Community Care charges the same amount for a pain appointment as for a primary care visit, and the out-of-pocket cost depends on the patient's insurance. Nearly half are on Medicare, either because they are older or because they qualify for federal disability benefits. About 33 percent are on Medicaid, the government health insurance program for the poor, and 20 percent have private coverage.
The conversations between Hawkinberry and his staff as they troubleshoot each case highlight just how complex pain can be.
"Degenerative joint disease of her sacroiliac joint, hip pain, fibromyalgia, tendonitis and osteoarthritis of her shoulders," was how one physician assistant, Jason Kidd, summed up a patient in her 50s last month.
"She's under a lot of stress," Kidd told Hawkinberry.
Hawkenberry refilled the woman's hydrocodone prescription and moved onto the next case, a new patient, a computer network technician with worsening knee and foot pain that his primary care doctor had not been able to help. In the initial screening of the 42-year-old man, a red flag emerged: He said that he had been taking some of his father's hydrocodone pills in an attempt to quell his pain.
"Was he contrite?" Hawkenberry asked Tracey Sherman, the physician assistant who had done the screening. "Was he obstinate?"
"Not obstinate," Sherman said. "Not argumentative at all. I think he just wants some relief."
Still, the patient had received a "moderate risk" score on the opioid risk assessment test that Sherman had given him, because he had taken his father's medicine and because of his relatively young age. Opioids were out of the question, at least for now.
After diagnosing plantar fasciitis in the patient's foot and ordering a knee X-ray, Hawkenberry gave him a non-narcotic, prescribed physical therapy and told him to come back in a month. If hydrocodone still showed up in his urine at that point, Hawkinberry warned, he would not see him again.
The patient gave his word.
"My other doctor couldn't find answers," he said. "So I'm just glad I could get in here."