Patients sign an 18-point contract. They have to get all medications at a single pharmacy. They must keep their medicine in a secure place, like a locked cabinet or safe. They can't share or sell their pills, and they can't use more medication than the doctor prescribes.
If they break the contract, the clinic will stop prescribing the medication.
Assessing pain is "incredibly time consuming," Chouinard said. Sometimes, the clinic's doctors determine they can treat a patient's pain with alternatives to medicine, like physical therapy.
When Chouinard became medical director in 2005, nearly 300 patients at the Clay site took narcotic pain medication. Today, it's fewer than 50.
One patient is a 47-year-old man who works at a dry cleaners where he does a lot of heavy lifting. He had gone to a pain specialist who said treatment other than pain medicine would not work.
The patient didn't want to give his name because he knows too many people whose homes have been targeted by burglars seeking pain medication.
"One guy left his house and he was gone 30 minutes to the store," the patient said. "And when he got back, they had already broken into the house. It's weird to have someone watching you that close."
He takes Lortab to relieve pain from a bulging disc and spinal stenosis.
When the patient's dentist wrote him a painkiller prescription for an abscessed tooth, he called Chouinard.
"The people that legitimately want and need pain medication are willing to live by that contract," Chouinard said. "Period."
Even with safeguards, some patients still get around the system. A few weeks ago, the staff saw a patient's name in the newspaper. He had been arrested for selling his hydrocodone pills.
Primary Care Systems hopes to strengthen its chronic-pain program, Malcolm said.
"What we want is the reputation in the community to be such that this isn't the place to go if you're trying to abuse the system."
The clinic plans to apply for grant money to keep improving the way it manages the patients, and is searching for a physician to travel to all its sites to treat clients with chronic pain.
That would free up staff to concentrate on patients with other chronic conditions like diabetes and hypertension, Malcolm said. Eventually, Primary Care hopes to partner with medical schools to train young doctors on treating chronic pain in a primary-care setting.
It's tempting for doctors to stop writing prescriptions for chronic pain, but Primary Care believes that's not the solution, Malcolm said.
"We knew that just turning people away wasn't going to fix the problem," Malcolm said. "You're just putting your head in the sand at that point."
Without medication, Chouinard's patient who works in the dry cleaners says he wouldn't be able to do his job.
"You would be filling out my disability paperwork," he told Chouinard.
This series was conceived and produced as a project for The California Endowment Health Journalism Fellowships, a program of the USC Annenberg School for Communication & Journalism.
Reach Alison Knezevich at alis...@wvgazette.com or 304-348-1240.