Pubdate: Fri, 13 May 2016
Source: New York Times (NY)
Copyright: 2016 The New York Times Company
Author: Abby Goodnough


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 that 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. Dr. Chouinard said Community Care was doing a 
better job of keeping them well over all, while letting Dr. 
Hawkinberry make all the decisions about who should be on opioid painkillers.

"I'm part F.B.I. investigator, part C.I.A. interrogator, part drill 
sergeant, part cheerleader," Dr. 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 
epicenter for opioid abuse from the 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 nonnarcotic drugs, physical 
therapy, injections and appointments with a psychologist.

Many had already been on opioids "for many years before they met me," 
Dr. 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 
anesthesiology resident, he said, and had to wage a legal fight to 
stay in the program. He relapsed four years later while working at a 
West Virginia hospital and underwent treatment and monitoring by a 
state program for doctors with addiction problems. He says he has 
been in recovery and has not used drugs for almost nine years.

Dr. Chouinard said that Dr. 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 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 Dr. 
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 Dr. 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 Dr. 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 Ms. 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, Dr. 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?" Dr. Hawkinberry continued, standing close 
and looking the man in the eye.

"No, 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.

Dr. Hawkinberry prescribed the patient a low dose of hydrocodone, 
five 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," Dr. 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."

He said he did not want to put anyone on a path to addiction. 
Referring to his own experience, he said, "I appreciate the cunning 
nature of this disease."

Dr. 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.

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.

Dr. Carl Sullivan III, director of addiction medicine at West 
Virginia University, said that Dr. 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 
examination, 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 Dr. Hawkinberry 
repeats at every follow-up appointment.

In another new case last month, the patient was 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?" Dr. Hawkinberry asked Tracey Sherman, the 
physician assistant who had done the screening. "Was he obstinate?"

"Not obstinate," Mr. 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 Mr. 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, Dr. Hawkinberry gave him a nonnarcotic, prescribed 
physical therapy and told him to come back in a month. If hydrocodone 
still showed up in his urine at that point, Dr. 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."

Editors' Note: May 11, 2016

This article has been updated to reflect information learned after 
its initial publication. A reader alerted The Times that Dr. Denzil 
Hawkinberry had abused opiates in the past. Dr. Hawkinberry in a 
subsequent interview acknowledged that he had gone through treatment 
for opiate abuse.
- ---
MAP posted-by: Jay Bergstrom