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 that have fuelled an epidemic of addiction and deadly overdoses.
"We needed to talk about congestive heart failure or diabetes or out-of-control hypertension," said 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 organisation'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 anaesthesiologist 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 anaesthesiologist, 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.
"I'm part Federal Bureau of Investigation investigator, part Central Intelligence Agency interrogator, part drill sergeant, part cheerleader," Hawkinberry said. He is also a recovering opioid addict who has experienced the difficulties of the drugs himself.
Even for people with access to the best doctors, it is hard to safely control chronic pain. Community Care is trying to do so for a disproportionately poor population, in a state that has been the epicentre for opioid abuse from the beginning of what has become a national epidemic.
Now, the difficult work of addressing the nation's over-reliance 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 per cent of the 1,200 patients currently in Community Care's pain management programme 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 was to get them on lower doses, and to try other ways of managing their pain, with his own experience as a cautionary lesson.
He became addicted to the opioid fentanyl when he was an anaesthesiology resident, he said, and had to wage a legal fight to stay in the programme. He relapsed four years later while working at a West Virginia hospital and underwent treatment and monitoring by a state programme for doctors with addiction problems. He says he has been in recovery and has not used drugs for almost nine years.
Chouinard said Hawkinberry's experience made him "all the better positioned to know what this is like" and to screen for drug abuse. 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 programme 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 licenced to operate under a 2012 law meant to cut down on pill mills.
The organisation'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 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 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.
©2016 The New York Times News Service
