CLAY, W.Va. -- When Dr. Sarah Chouinard interviews doctors to work in rural clinics, they all want to know the same thing.
Will I have to treat pain patients?
It's always the first question they ask. "Immediately," she said, snapping her fingers.
The doctors don't want to write prescriptions for narcotic painkillers.
"They hate it," she said. "And they hate it because it's a moral dilemma."
How do they know their patients won't sell or abuse those pills?
Chouinard is medical director of Primary Care Systems, a group of community health centers serving Clay County and surrounding areas. In the face of widespread prescription drug abuse, her center is trying new ways to manage patients who take medication for chronic pain.
Primary Care Systems, which is merging with Tri-County Health Clinic, has streamlined the way it cares for these patients. It sets strict rules to weed out those who are abusing or selling their medication. Painkillers are the most abused type of prescription drug in the state.
"West Virginia is one of the worst places for prescription drug abuse, but it's also one of the places that I think has a high rate of legitimate chronic pain," Chouinard said.
Many of her patients work in labor-intensive jobs, she said. Some work in the coal industry. Others trim trees, or do mechanical work on heavy machinery.
For many of Chouinard's patients, traveling to a pain specialist isn't an option. Nearly one in four Clay County residents lives in poverty. Its unemployment rate is the highest in the state, nearly 15 percent at last count.
"There are people that have never been to Charleston," which is 45 miles away, Chouinard said.
Prescription drug abuse has caused "a growing fear of primary care providers to even treat chronic pain patients," said Brock Malcolm, chief operating officer of Primary Care Systems.
"We have a mission to try to help the people who aren't being reached. That's what community health centers do," Malcolm said. "There was clearly this population who was not being able to get care because of the stigma of people who abuse the system."
He remembers doctors arguing about the issue in staff meetings.
"Certain doctors were filled up with pain patients," he said. "If you were willing to do it, [all the patients] would get dumped on you."
To be more efficient, the clinic now makes all chronic pain patients schedule their appointments on one day of the week.
"On that day, we're kind of in the mode," Chouinard said.
Before she even walks into the exam room, she's armed with a Board of Pharmacy report showing which prescriptions her patients have filled, and the results of a urine test and pill count.