Deep in the hills of West Virginia, Sarah Chouinard, M.D. and Rick Simon had a problem.

Their region's long roads and steep mountains kept people from seeking medical care. Few would ride a bus for an hour for a diabetes or hypertension screening. So they expanded Community Care of West Virginia — the FQHC where they serve as medical director and CEO, respectively — from three scattered clinics to nearly 50 primary and urgent care health centers, school-based clinics, and pharmacies.

But all those far-flung offices meant staffing up Community Care’s primary care team. And West Virginia, like 77 percent of rural regions, does not have enough doctors. Young doctors tend to practice where they’re trained, in and near urban centers.

And they don’t want to spend their days negotiating pill counts with opioid patients.

The opioid crisis roiling the nation wasn’t just wreaking havoc on Community Care’s patients. It was putting the brakes on the organization’s ability to recruit physicians and grow.

Could Chouinard and Simon address both problems at once?

A challenge to recruiting

West Virginia is home to mining, timber, and other industries that rely on manual labor. High rates of physical injury have fueled high rates of pain medicine use and abuse. Today, the state suffers the highest rate of opioid overdoses in the nation.

For local primary care doctors, daily patient care means parsing out which patients are trapped in addiction, who truly needs pain relief, and how to deliver it safely. Little time and focus is left to manage equally rampant hypertension, obesity, and diabetes.

That’s not the kind of primary care Gregory Peters, M.D., envisioned when he went to medical school. A born-and-raised West Virginian, he had always wanted to practice family medicine close to home. Yet even Peters had his doubts.

“All the residents in our graduating class did,” he says. A poll of his class at the West Virginia University Health Sciences Center identified their top three concerns in choosing a first job: location, compensation, and the opioid epidemic.

“As we approached potential employers, we all asked what their pain management policy was,” Peters recalls. Residents knew that if an organization did not already have a program to address patients’ opioid dependency and abuse, “you’re it.”

Chouinard knew the doctors she wanted to hire were worried about pain management. So she and Simons developed a program designed to both reduce opioid use among patients and draw new doctors to work in remote clinics.

One doctor for all pain patients

Their innovation? They recruited a single pain specialist, Denzil Hawkinberry M.D., to oversee the care of all pain patients. A board-certified anesthesiologist, Hawkinberry left a career in the surgical suite to dedicate his days to treating pain patients effectively and safely — and relieving primary care doctors of the intricate decision-making each patient requires.

In 2012, his first year with Community Care, Hawkinberry oversaw the care of 793 pain patients. By 2016, that number had risen to 1,315. All in all, 10 percent of Community Care’s patients have visited the pain management program.

Referred by the primary care team, each patient meets with him for a thorough, hour-long physical exam where medical and psychological histories are reviewed, prescriptions are cross-checked against the state’s database, and risk of addiction is assessed.

Alternative therapies — from physical and behavioral therapy to steroid injections, over-the-counter pain relief and, if necessary, inpatient detox — are integrated into treatment.

When Hawkinberry determines that pain medication is warranted, patients must sign a contract setting terms for use, and are monitored to ensure compliance via urine tests and pill counts at every appointment. Following the assessment, Medicare or cancer patients may be released back to their primary care providers with intermittent visits to Hawkinberry’s team.

“The focus of our push to get patients to Dr. Hawkinberry,” says Chouinard, “is not for him to write every single opioid prescription, but to facilitate the care of patients with chronic pain. Because that’s really where, frankly, the problems lie.”

Hawkinberry points to one 46-year-old patient who entered the pain management program taking large doses of methadone for 10 years for lumbar, hip, and knee pain. A thorough examination determined that his primary problem was not pain, but chronic opioid dependence, obesity, depression, and a sedentary lifestyle.

Weaned off methadone, the patient was able to handle his modest pain levels with steroid injections and NSAIDs. He began an exercise program that alleviated his depression and helped him lose 40 pounds. And his primary care doctor was able to treat his hypertension. In time, the patient reported a happier life and a better relationship with his wife.

Results like that were all that Gregory Peters needed to hear.

“The thought that I could treat patients without having to deal with the chronic pain issue was really appealing,” says Peters, “because I could say to patients, ‘Okay, we have a way to help your pain. Let’s talk about your medical problems.’”

Delivering care, not opioids

Simon and Chouinard say they can already see the program’s effects on day-in-day-out primary care.

Data from more than 100,000 visits to their primary care physicians since the program was established shows a steady rise in physician focus on chronic diseases, paralleled by a drop in opioid prescribing.

“If we’re not dealing with the chronic pain issues, look how much more time we have to deal with their lipids, their hypertension, their diabetes,” says Kelly Dunavant, M.D., a family physician with Community Care.

Simon and Chouinard point out that the organization’s dramatic growth — from 24,000 to nearly 40,000 patients over three years — has drawn in many new patients with untreated complex chronic diseases. Yet their primary care doctors are still able to deliver quality care without being overwhelmed by pain and dependency issues.

And Community Care’s approach to pain management has infused new energy throughout the organization.

“The pain management program has allowed us to recruit young providers,” says Simon, “and with their enthusiasm, quality improves automatically.”

He and other leaders say the program has not only staffed clinics with young doctors, but also with the right doctors.

The expanded team is “passionate about this work, passionate about prescription drug abuse, passionate about making sure that the pain management needs of their patients are met,” says Hawkinberry. “And when you’re doing something that you love, it doesn’t seem quite so hard.”

Gale Pryor is a senior writer for athenaInsight. Data analysis by Anna Zink. Photography by Sam Owens.