COLEBROOK, N.H.—Inside a dimly lit room at the largest health care provider in New Hampshire’s least populated county, a circle of drug addicts talk about how to recover.
In this private setting a reporter agrees not to publish the addicts’ names, but most people in and around Colebrook, a decaying town of 2,300, know who they are because of what they’ve become.
“Once you become known as an addict, once you get that name, it stays with you, especially in a small town,” says a bearded mechanic in his late 30s, who says he has been sober from opioid painkillers and heroin for a year.
Part 3 of 5: ‘Dr. Father Pill’ Wants to Be Part of the Solution
He’s trying to stay that way with the support of his girlfriend, a fellow addict and participant in the group therapy session who recently served seven months in jail for selling drugs to pay for her own use.
Among other offenders in the jail, her frail frame marked her as an addict, she says.
“Being an addict, you lost track of values,” the woman shares with the four peers around her, who nod their heads to relate.
“I am not perfect. I have had slip-ups,” she adds, her voice trailing off without completing the thought.
Indian Stream Health Center, the provider hosting the meeting—known formally as an intensive outpatient treatment program—is also the largest prescriber of pain medicine in Coos County, where the town of Colebrook is located.
That means, at a time when Coos County, like America, is experiencing record numbers of deaths related to opioids—including prescription painkillers and heroin—Indian Stream Health Center is trying to resolve a problem it helped create.
No one is more sensitive than John Fothergill to the conflict of providing medicine to people whose pain demands it, but whose bodies can’t tolerate overuse of it.
Fothergill, an Indian Stream physician, is known by some Coos County residents as “Dr. Father Pill.”
The derogatory play on the doctor’s name is a response to a story in the New Hampshire Union Leader finding that Fothergill, in 2013, was the top physician prescriber in the state of the opioid oxycodone hydrochloride, sold under brand names such as OxyContin.
“I have heard that some people say my name is Dr. Father Pill,” Fothergill, 62, tells The Daily Signal in an interview, revealing the nickname without a reporter asking about it. “We certainly prescribe this medicine, and some became addicted to it. I am quite sure I am part of the problem. I am not so naive to say I am not. Right now, I am trying to be more a solution than a part of the problem.”
‘They Blame Me’
When a reporter makes a late April visit to Coos County, New Hampshire’s poorest, several residents bring up Fothergill—by the nickname Father Pill—in describing how an opioid epidemic began here.
Fothergill does not enjoy being the butt of jokes, his name connected to the most unfunny of designations: Coos County has the highest combined death rate due to drugs, alcohol, or suicide in all of New England.
This statistic is felt intimately in a county that is New Hampshire’s largest by land mass—1,830 square miles—but smallest according to population. Coos’ 33,000 people represent less than 3 percent of the state.
Yet Fothergill doesn’t hide from his role in a complex problem, eager to provide context about how doctors like him fit into the multilayered supply chain of opioids.
From 1999 to 2013, the amount of opioids prescribed in the U.S. nearly quadrupled, according to the Centers for Disease Control and Prevention, and about 2 million Americans today are addicted to them.
According to the Union Leader, Fothergill issued 1,066 prescriptions and refills of oxycodone HCL, or OxyContin, in 2013.
Since that story appeared, Fothergill has made himself more visible. He offered a rebuttal to the Union Leader, saying in a letter to the editor that the story drew an incomplete conclusion since it did not list the number of patients involved or the quantity of medication dispensed.
The story also did not take into account the socioeconomic standing of a particular region, which Fothergill says is relevant because low-income residents are less likely to be able to afford alternative pain treatment such as physical therapy.
Fothergill not only is approaching his 30th year as a physician at Indian Stream, but he also recently became a New Hampshire state legislator. First elected to the state House of Representatives as a Republican in 2014, he has taken on a prominent role in pushing the medical industry to self-regulate as a member of the Health, Human Services and Elderly Affairs Committee.
Part 1: The Crisis That May Have Swung Voters From Obama to Trump
Part 2: One Opioid Addict Helps Another Choose Life Over Death
Part 3: ‘Dr. Father Pill’ Wants to Be Part of the Solution
Part 4: Police Assault on Opioids Gets Boost From a Family Doctor
Part 5: The First Responders Who Witness a Dreadful Toll
“I got elected to the state Legislature without even campaigning,” Fothergill says. “So if you lined up every citizen in Colebrook and said, ‘Is Dr. Fothergill a plus or minus?’ the vast majority would say I am a plus in the community for all the work I have done over the years.”
“People are looking for someone to blame, and they blame me or the health center [Indian Stream] and there’s not much I can do about that. I sleep well at night.”
‘Blame to Go Around’
Indian Stream Health Center is one of 11 federally qualified health centers in New Hampshire, meaning it provides comprehensive services—primary care, dental, mental health—to an underserved area. This designation means it qualifies for federal funding and enhanced reimbursement under the Medicare and Medicaid programs.
Because the center offers services for all kinds of care—to about 4,000 patients per year, regardless of their ability to pay—Indian Stream doctors prescribe more medication than any other provider in the area.
Fothergill says strong demand exists in Coos County for pain medicine because many patients are low-income and uninsured, meaning their treatment options are limited.
“If somebody who walks into the office says, ‘I have back pain,’ there is a whole array of things one may do,” Fothergill says. “In Coos County, a lot of those things are not available to us, so probably more often than not, we prescribed pain medicine. Hopefully they would get better and come off of them.”
“Certainly,” he says of the opioid crisis, “the environment was sort of ripe for this to happen.”
Fothergill is not alone in responding aggressively to that environment.
Pete Moran, a physician in family practice at Indian Stream, ranked sixth in the Union Leader’s ranking of top opioid prescribers in 2013.
Moran says that in the 1990s, manufacturers of opioid painkillers marketed the drugs as an elixir to treat pain and downplayed potential harm.
“I have been in practice since the 1990s, when there was a period of time where the idea was that we weren’t adequately controlling pain,” Moran tells The Daily Signal in an interview. “There was a big campaign by the pharmaceuticals to prescribe their medicines.”
The family practitioner says he was personally threatened by a patient for whom he refused to prescribe pain medicine.
“All of the opioids, if used at a high enough dose long enough, will create a dependence: a physical and chemical dependence,” Moran says, adding:
But not everybody that is chemically dependent on an opioid is addicted. Someone who is addicted to a medicine is not just dependent on the medicine, but they also crave the medicine. It gives them a feeling of euphoria, and their life takes on a dimension where they are looking for the drug. You need to find the cause of that pain so you can treat it and fix it. Maybe as doctors we don’t do that well enough. I don’t know.
Caleb Alexander, co-director of the Johns Hopkins Center for Drug Safety and Effectiveness in Baltimore, says prescribers are one peg in a supply chain that has churned out opioids in historic numbers.
The federal Food and Drug Administration has been criticized for too liberally approving painkillers pushed to market by drug manufacturers.
Numerous news reports, meanwhile, have documented how the Drug Enforcement Administration has failed to hold accountable distributors and manufacturers that were creating and shipping millions of painkillers to be prescribed in communities across the U.S.
In Congress, the House Energy and Commerce Committee recently opened an investigation into reports that the DEA reduced enforcement efforts against painkiller distributors during a lobbying campaign by the industry.
“There is plenty of blame to go around and many different parties have played an important role in propagating the opioid epidemic,” Alexander says in an interview with The Daily Signal. “But there’s a very clear correlation to the volume of opioids prescribed and injuries and deaths from these products. So high-volume prescribers are a very important part of the puzzle.”
‘Work Ourselves Out of a Job’
In response to the trend of overprescribing, the state of New Hampshire in January implemented new protocols requiring medical professionals to conduct a risk assessment before prescribing opioids.
Patients also must sign an informed consent form, which allows doctors to access a database in the state’s prescription drug monitoring program to ensure the patient isn’t seeking drugs from multiple doctors.
Fothergill helped shape the legislation requiring these regulations from his perch on the health committee.
“The rules and regulations we came up with were a good compromise,” Fothergill says. “It makes physicians think about what they are doing. You are not just giving a prescription for 30 days and hoping for the best.”
Fothergill also pushed for expansion of Medicaid in the state, which, under Obamacare, requires addiction services and mental health treatment to be included as part of the health care program for the poor.
In Coos County last year, 5.4 percent of residents were covered under the program—more than in any other county in the nation.
Indian Stream is taking these new rules a step further, requiring patients who receive prescription pain medicine for 28 days or longer to participate in treatment at the facility, such as a substance abuse class or group therapy.
As part of services such as the group therapy session attended by The Daily Signal, social workers employed by Indian Stream—the center has five of them—inform patients about the drivers of their addiction.
These social workers try to help patients resolve related life “traumas” that may make them susceptible to addiction.
Coos County is routinely ranked last in the state for quality of public health, measured by indicators such as length of life, diet and exercise, income, access to housing and transportation, and drug and alcohol use.
“The risk of addiction increases based on how much trauma you have experienced,” Laurie Connors, Indian Stream’s director of Behavioral Health Services, says in an interview with The Daily Signal. Connors adds:
Substance abuse is a coping mechanism for pain. You are continuously feeding this cycle and never getting at the root cause of the issue unless you address the social determinants of health—unemployment, domestic violence, poverty.
Indian Stream also offers medication-assisted treatment, a fast-growing response to addiction in which doctors prescribe nonaddictive painkillers that can be used to counteract the effects of opioids.
Seth Leibsohn, co-director of Americans for Responsible Drug Policy, argues that treatment alone won’t stop the opioid addiction epidemic.
“Most of the efforts dealing with the opioid crisis are geared toward recovery, which is important and not to be ignored, but no one is doing prevention,” Leibsohn says in an interview with The Daily Signal. “You want to save all the lives you can. Recovery is really hard. You want to do everything you can, but how about stopping the problem before it starts?”
Leibsohn, a former chief of staff to William Bennett, the nation’s “drug czar” under President George H.W. Bush, says the best way to prevent drug misuse is to educate people about its dangers. He contends that a strong public relations campaign can overcome other factors that may influence drug misuse.
“I have heard often enough from people that opioid addiction is a disease of despair,” Leibsohn says, adding:
While I get that, I don’t want to fall into the trap where we think economics drive substance abuse. I do think people try to anesthetize themselves from problems. But the main driver is not economic. We have given up on the message that drugs are dangerous. There is a cultural message that has destigmatized the problem of drug use that has been going on for close to two decades.
Back in Coos County, Jonathan Brown, Indian Stream’s CEO, says his health care center has a “responsibility” to provide treatment services and better manage its prescription procedures.
Brown, who started work at Indian Stream 13 years ago in an information technology job—giving him a pragmatic perspective—says treating the causes of pain will improve the wellbeing of the community, even if his bottom line suffers because of it.
“A part of our greater responsibility is to help change people’s beliefs about the stigma of mental health and substance abuse, to overcome a culture of hopelessness that has been fostered in Coos County,” Brown tells The Daily Signal in an interview. “Every day our job is to work ourselves out of a job.”
‘Not Going Anywhere’
Despite his efforts to make amends, Fothergill knows the whispers about him won’t go away.
The physician acknowledges that Coos County remains in a drug crisis, and says he regrets not pushing back harder on patients who sought pain medicine but could have been treated first with less risky alternatives.
Fothergill says he plans to retire soon, and vows to spend the rest of his life in Coos County.
“I am not going anywhere,” Fothergill says, adding:
I certainly feel very bad for anyone who may have become addicted because of the medication I started them on, and we don’t want to be creating any more addicts. Aside from the opioid stuff, I actually think I do a pretty good job. For everyone who says I am Dr. Father Pill, multiple patients would say I am the doctor they want to see.
Next, in Part 4: The family doctor who works with police to fight the local opioid epidemic.