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.

Read main story from Day 2: Medical community grapples with prescription drug abuse epidemic

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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.

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.