STEVE INSKEEP, HOST:
For seven years now, doctors across this country have been prescribing fewer opioids than in the past. They better understand the dangers of addiction to the painkillers. But that is a national figure. In rural areas, opioid use remains significantly higher than elsewhere. One rural doctor wants to change that. Wisconsin Public Radio's Bram Sable-Smith begins this story with one of her patients.
BRAM SABLE-SMITH, BYLINE: One reason there's more opioid prescriptions in the rural U.S. is that rural Americans simply have more chronic pain. They tend to be older, so painful conditions like arthritis are more prevalent. Injuries also seem to be more common in rural areas, as do labor-intensive jobs. For Michael Kruchten, the pain began with the chemo and radiation therapies he received for lung cancer back in 2011.
MICHAEL KRUCHTEN: I did not respond to it very well. They started me out with the chemo. It was very harsh.
SABLE-SMITH: Kruchten's 62 now and cancer-free. But the treatments left him with permanent and severe nerve damage in his hands and feet.
KRUCHTEN: A lot of aches and pains - like last night, I was sitting in my recliner and talking on the phone. And all of a sudden, I get a real sharp jolting pain, like in my big toe.
SABLE-SMITH: The pain was so bad, Kruchten had to stop working at the ethanol plant near his home in Necedah, Wisc. Daily chores like chopping wood for his furnace or even carrying a plate of food became challenging. And maybe worst of all, the pain would keep him awake at night.
KRUCHTEN: A lot of nights, I pounded the pillow trying to get sleep. I'd get so frustrated and restless that I was pounding the pillows just to try to get to sleep.
SABLE-SMITH: Kruchten brought up the pain with his family physician, Angela Gatzke-Plamann. She's the only full-time doctor in the central Wisconsin village; only 916 people live here. Her patients call her Dr. Gatzke to avoid confusing her with her husband Dr. Plamann, the county's only pediatrician.
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ANGELA GATZKE-PLAMANN: Hello.
KRUCHTEN: How you doing?
GATZKE-PLAMANN: Hi. Thanks for waiting. Good. How are you?
SABLE-SMITH: Dr. Gatzke tries to avoid prescribing opioids when she can, but alternative treatments for pain are limited around here. The nearest physical therapy is a 17-mile drive away. Other treatments, like cognitive therapy, require an even longer drive - at least an hour. For Michael Kruchten's pain, she first tried prescribing one, then two nerve pain medications, neither of which quite helped enough. Eventually, she prescribed the opioid hydrocodone. That finally gave Kruchten enough relief to sleep at night.
GATZKE-PLAMANN: So what sorts of things are you able to do because your pain is alleviated to the point that you can sleep?
KRUCHTEN: Well, without the sleep, I was a couch potato.
SABLE-SMITH: Necedah's not exactly the center of the opioid epidemic. The overdose death rate in this county is about in line with the Wisconsin state average. But the next county over has one of the highest overdose death rates in the state. And when Dr. Gatzke came to Necedah in 2010, opioid prescribing was hitting its peak.
GATZKE-PLAMANN: We were all seeing that in our practice, too. We were seeing that some patients were losing control of their ability to use these. It became very problematic.
SABLE-SMITH: Dr. Gatzke made a concerted effort to reduce opioids. Today she only has about 10 patients on monthly prescriptions, and she asked them all to sign something called a medication treatment agreement. These are contracts that essentially lay out the rules for getting an opioid prescription. Patients like Michael Kruchten have to agree to stipulations, like only getting opioids from Dr. Gatzke and submitting to random pill counts. Kruchten's something of a model patient in that regard.
GATZKE-PLAMANN: You come in for appointments regularly, and you're always on time. And if I ask for something - like, if I asked to have a urine drug screen to make sure that you're not using other substances, that - you'll do that.
SABLE-SMITH: If a patient violates the agreement, Dr. Gatzke can stop prescribing them opioids. But the point of these contracts is not about punishment; it's about communication. They're an opportunity to remember the risks and warning signs of addiction.
KRUCHTEN: Last night, I had only taken one hydrocodone instead of two. And it was satisfactory with the discomfort and the pains I had in my feet.
GATZKE-PLAMANN: Yeah. And that's good that you don't take it to just put yourself asleep - right? - I mean, 'cause it's not a sleep medicine. Good. Thanks for coming. We'll see you soon.
SABLE-SMITH: One Friday afternoon, Dr. Gatzke realized there was another crucial element missing in Necedah - treatment for addiction. She got a call from a patient in crisis. He'd lost control of his use of opioids, and he needed help.
GATZKE-PLAMANN: I didn't have any resources to be able to give him. I was literally sitting in this office Googling, while we're talking on the phone, someplace where he could get help in the area.
SABLE-SMITH: And there was nothing available. Something needed to change. So last year, Dr. Gatzke started prescribing buprenorphine. It's an effective medication for addiction, but it's nowhere near as accessible in rural America as in urban parts of the country. More than 10 million rural Americans live in a county where there is not a single clinician who can prescribe the drug.
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CATINA STOFLET: How are you?
GATZKE-PLAMANN: Good. How are you?
STOFLET: OK. I'm tired.
SABLE-SMITH: Catina Stoflet is one of Dr. Gatzke's patients. Thirty-five years old now, Stoflet started getting kidney stones back in high school. She's had many surgeries to remove the painful obstructions. She was also prescribed opioids. From there, her story takes a familiar turn.
STOFLET: I started becoming addicted to the pain medication.
SABLE-SMITH: Stoflet has struggled with addiction since she was 16, progressing from prescription opioids to heroin and meth. In May, Dr. Gatzke started her on buprenorphine.
GATZKE-PLAMANN: Are you having any side effects right now from the buprenorphine - any constipation?
SABLE-SMITH: Dr. Gatzke's buprenorphine patients also have to sign contracts. Part of their agreement is to participate in a treatment program that goes beyond just the medicine. Stoflet works with a counselor and a recovery specialist at a recovery center that opened recently about 20 miles away from Necedah. Stoflet herself lives another 30 miles north of there.
STOFLET: Yeah, sometimes it's a lot of driving.
SABLE-SMITH: Even so, Stoflet says her frequent visits with Dr. Gatzke are worth the drive for more than the prescription.
STOFLET: I never thought I could have that, like, kind of relationship with my doctor.
SABLE-SMITH: The opioid crisis is not as simple as one or two people's stories. It's more complicated than the number of overdose deaths or pills prescribed in a given county. But it is real and present here in Necedah. Dr. Gatzke can see that.
GATZKE-PLAMANN: I have to respond to what's going on in the community, and I have to listen to what it is that my patients need.
SABLE-SMITH: And so with the limited resources available to her, she does what she can.
For NPR News, I'm Bram Sable-Smith in Wisconsin.
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INSKEEP: That story comes to us from a reporting partnership between NPR and Wisconsin Watch.
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