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.
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.”
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.”
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. Instead, it has relied on four physician assistants who work with Dr. 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,” Dr. 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 Dr. 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 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 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 Dr. 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 Dr. 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, tendinitis 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,” Mr. Kidd told Dr. Hawkinberry.
Dr. Hawkinberry 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? 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.”
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.