Harry Rinehart’s House of Pain

From its perch on a steep hillside in Wheeler, Ore., the Rinehart Clinic offers a view of the timeless battle between the Nehalem River and the Pacific Ocean.

When the tide flows out, water rushes toward the Pacific through the Nehalem estuary, where shrieking osprey hunt salmon and marooned trees washed down from the Coast Range create a natural sculpture garden on the bay shore.

Twice a day, the power of the incoming tide reverses the Nehalem, and the rising saltwater blankets the estuary's flats, submerging the blackened stumps of old pier pilings that line Wheeler's waterfront like an addict's teeth.

To some residents of Wheeler, a Tillamook County town of 414, what happens inside the Rinehart Clinic is also a daily miracle.

Dr. Harry Rinehart, like two generations of his family before him, cares for the sick in this coastal region, regardless of their ability to pay. His patients, often wracked with despair, poverty and pain, are those other doctors refuse to see.

Not in the eyes of law enforcement.

At 11 am on May 16, nine agents from the U.S. Drug Enforcement Administration raided the Rinehart Pharmacy, which is adjacent to and owned by the Rinehart Clinic. DEA officials had persuaded a federal judge to issue a warrant based on "red flags" regarding the "prescribing practices" at Rinehart's clinic. When finished, the agents carried out dozens of files and stacks of other documents detailing the pharmacy's inventory and handling of controversial opioid pain medications such as morphine, methadone and OxyContin. The DEA declined to comment.

Oregon leads the nation in the abuse of such drugs, federal statistics show, with the state's rate of prescription drug abuse 39 percent higher than the national average. Law enforcement and health-care officials are desperately fighting what the Centers for Disease Control and Prevention has termed "the deadly epidemic of prescription painkiller abuse."

More Americans die annually from drug overdoses than auto accidents, according to the CDC, and most overdoses are related to prescription drugs. The problem is worst in small towns such as Wheeler, already beset by the challenges much of rural Oregon faces: high employment, low educational attainment and-—over the past decade—skyrocketing prescription drug availability.

When pain pills are easy to get, the supply feeds a black market. Addiction to pain meds often leads users to heroin, which is cheaper than pills. The high number of heroin overdose deaths in Oregon, experts say, is directly related to the flood of pain pills doctors have unleashed.

Last year, Oregon doctors prescribed 100 million pain pills—on average 25 for each person in the state. And federal records show Rinehart is one of the top prescribers of opiate meds in Oregon, even though he's never been certified in pain management.

The conflict over Rinehart and his clinic is part of a national battle, one as powerful as the clash of tide and river in Nehalem Bay.

"There's a lot of debate about when and whether opiates are appropriate," says Dr. Mark Bowman, chief of emergency medicine at Tillamook Regional Medical Center, where many of Rinehart's patients end up. "And there's a lot of debate about how best to treat pain patients."

Bowman declined to discuss Rinehart's practices.

All the scrutiny makes the kinds of patients Rinehart specializes in treating—chronic pain patients and opiate addicts—less appealing to other physicians.

Rinehart, 68, is unfazed by the DEA investigation, which could lead to civil sanctions or even criminal charges. He's been in the cross hairs of local and state officials for years, and no one has been able to hang any violations on him.

Rinehart casts his work in moral terms, saying his commitment to medicine and treating the people of his community is "a calling stronger than the clergy."

"A lot of doctors discriminate against pain patients and addicts," he says. "That seems wrong—that if you get a certain diagnosis, you can't be treated."

Gale Taylor, a former chief financial officer at the clinic, says she thinks Rinehart's desire to preserve his family's history has clouded his judgment.

"He's carrying on his parents' legacy," Taylor says. "That's his pride and joy. But somewhere along the way, he lost sight of what he's doing and why he's doing it."

From Portland, travelers approach Wheeler on Highway 101. On the Nehalem Bay side, the Wheeler Marina rents kayaks and the Tsunami Bar & Grill provides most of the town's eating and drinking options. No traffic light or stop sign halts the traffic on 101, but most days it's a trickle. A string of antique and gift shops lines the main street. One large storefront—the former Wheeler Pharmacy—remains papered over, four years after a prescription drug scandal shut it down (see "The Pharmacy," at bottom).

Economic conditions in Tillamook County are dismal. The county's population of about 25,000 is significantly older and poorer than state averages. Wheeler residents are even worse off: Census data shows that median household income is $31,000, about 60 percent of the average Oregon household.

"You can hide poverty in the city because there are so many people," says Ellen Boggs, CEO of the Rinehart Clinic. "But you can't hide it out here."

In 1913, Dr. Harvey Rinehart came to Wheeler from Portland to serve workers and their families at what was then, according town history, the largest sawmill on the West Coast. The town—named after Coleman Wheeler, the great-grandfather of State Treasurer Ted Wheeler—was booming: A railroad hauled in logs even before Highway 101 existed, and canneries lined the waterfront.

A year later, the mill closed. The doctor and his wife decided to stay. "They ate a lot of blackberries and clams that first winter," Harry Rinehart says of his grandparents.

Family doctors in the early part of the 20th century often developed specialties. Some created their own recipes for tonics to purify the blood. Others favored the use of leeches for bloodletting. Rinehart's grandfather focused on developing remedies for pain suffered by the workers who toiled in the forests.

Harvey Rinehart developed an arthritis injection, a treatment that continued under his son, Dr. Robert Rinehart, and his daughter-in-law, Dr. Dorothy White Rinehart, also a physician.

The Rinehart clinic became a destination for medical tourists. "Even with the decline of timber and fishing, Wheeler thrived in the '40s, '50s and '60s partly due to the Rinehart Arthritis Clinic in the center of town," according to the city's history. "People came from around the country to take Dr. Rinehart's miraculous cure."

That he would join the medical profession was never in doubt for Harry Rinehart, who graduated from the University of Oregon Medical School in 1972.

After a stint as a military doctor, he bought a clinic in Prineville in Central Oregon in 1982. But as his parents aged, Rinehart decided to return to Wheeler. In the '80s, Wheeler was depressed. High interest rates crippled the homebuilding industry, which in turn decimated the logging business. Fishing was also on the decline. Wheeler began to resemble a ghost town, an emptied-out community that once supported two grocery stores, two drugstores, a bank, a movie theater and its own K-12 school.

The Rinehart Clinic was barely surviving. Rinehart converted it into a nonprofit so it could seek tax-deductible contributions.

The clinic's annual Sand Dollar auction is one of the social events of the summer for wealthy retirees and second-home owners on the North Coast. Last year, for its centennial celebration, the clinic's auction raised $100,000—an extraordinary accomplishment in such a sparsely populated area. Most years, the region's most powerful politician, state Sen. Betsy Johnson (D-Scappoose), takes to the stage to exhort the crowd to open their wallets for the Rinehart Clinic. Johnson's family foundation gives at least $5,000 every year.

"A lot of people appreciate the work he's done to provide health care to people with low incomes," Manzanita Mayor Garry Bullard says of Rinehart. "There are a lot of people who have been served by him and are worried about what will happen when he retires."

Rinehart, already past retirement age, shows no sign of slowing down.

He took up scuba diving at an age when most people are joining AARP. He hunts elk, forages for mushrooms and still pilots his Zodiac inflatable boat in search of crab. "He's fearless going over the Nehalem River bar," Boggs says. "He has even been known to dump people out of the boat when he's doing it."

Rinehart strides around the clinic like a vigorous grandfather: His snowy white hair and red-tipped nose are the clinic's weathered face, and his booming voice its soundtrack.

Rinehart is old school, dressing for work on a recent day in a blue blazer, cuffed gray-flannel slacks—secured by a belt and suspenders—polished brown brogues and a neatly knotted tie with a miniature-duck pattern over a pressed blue-and-white checked shirt.

He's a schmoozer, wandering the clinic with a mug of black coffee in hand and a stethoscope slung over his shoulder. He's also a lively and prolific writer, whose quarterly newsletter bears titles such as "A While in the Life of a (Now Old and Fat) Country Doctor."

The Rinehart Clinic is housed in a low-slung, clapboard-sided building owned by the Nehalem Bay Health District. Thick plate glass separates a receptionist from the patients who sit in a cramped waiting room dominated by a wall-sized map from the 1940s. The map is dotted by pins showing all the places across the U.S., Canada and Mexico where patients traveled from to visit the clinic.

The clinic serves 3,000 patients and, according to its tax returns, generated $2.3 million in revenue in 2012. Nearly 60 percent of those patients had household incomes of less than $23,850, the federal definition of poverty for a family of four, and more than a quarter of them had no insurance. As medical director, Rinehart earns a salary of $168,000.

The clinic offers urgent care, mental-health counseling, and in keeping with Rinehart's aggressive approach, engages in experimental treatments such as injecting severely depressed patients with ketamine, more typically used as an animal tranquilizer. That unusual use of the drug has not been approved by the U.S. Food and Drug Administration. But Rinehart is best known for his work with addicts and chronic-pain patients.

"He's a very caring person," says Deborah Burr, 60, of Nehalem, who's been seeing Rinehart for arthritis pain for seven years. "Without him, I couldn't work."

Trinidy Richardson, 36, a roofer from Astoria, says cyclic vomiting syndrome made his life hell for a decade. He'd wake up vomiting and miss work, making it difficult to support two daughters and a girlfriend.

"I went to the emergency room 89 times in nine years," Richardson says. "I saw several doctors throughout that time. They all said they couldn't help me."

In March 2013, Richardson went to see Rinehart, who put him on a regimen of vitamins; antidepressant and anti-anxiety medications; and methadone, an opiate, for his pain. Richardson says the vomiting ceased.

"He's a godsend," Richardson says of Rinehart. "He's been my savior."

Other doctors in the area, such as Dr. Rex Parsons, who's practiced in Tillamook since 1983, are less enamored of powerful prescription pain meds. "Chronic pain and addiction often co-occur," says Parsons, who declined to discuss Rinehart's prescribing practices. "Without the ability to identify and treat addiction, the use of high-dose opiates is often misdirected, inappropriate and harmful."

Of the clinic's nearly 3,000 patients, Rinehart treats 300 for chronic pain, and another 100—the maximum allowed under federal law—for an opiate addiction he treats with the drugs Suboxone and Subutext.

Rinehart sees most of those patients in group settings. That's an unusual approach, one that state Medicaid officials say is legal, provided all patients get their vital signs checked and consult with Rinehart

On a recent Tuesday, Rinehart saw three addicts simultaneously. A woman with a bold magenta streak in her hair told Rinehart she was worried about an upcoming gall-bladder operation and the possibility she might get hooked again on pain meds in the hospital. A sad-eyed Garibaldi construction worker, who nervously adjusted his hat bearing the logo of Stihl chain saws, says he relapsed recently after his ex-girlfriend moved his son to Oregon's South Coast. Another woman says she's trying to regain custody of her daughter after relapsing and being jailed. She shows photos and a brief video of her daughter on a pink smartphone.

"Adorable," says the woman with the magenta hair.

Rinehart spends a few minutes listening to his patients, then renews their prescriptions; most head to the adjacent pharmacy, which his clinic owns, to have them filled.

Although he sees up to 10 patients at a time in his groups, Rinehart says his motivation for doing so is patient well-being rather than increased revenue. He says patients support each other and hold each other accountable.

"Patients like it," Rinehart says. "Almost all of them will tell you they really benefit from being together. But we're not herding cattle here. We are making sure all their issues get addressed."

A 2013 report from the federal Substance Abuse and Mental Health Services Administration found that Oregon has the highest rate of opiate abuse in the nation.

Nobody is sure why. One explanation is that Oregonians, who pioneered Death With Dignity and medical marijuana, are predisposed to palliative measures.

"We were in the forefront of the movement to recognize people's pain," says Dr. Jim Shames, the public health officer in Jackson County, "and we just went a little too whole hog."

For more than a decade, Rinehart has faced concerns over his prescribing practices. In 2006, the Oregon Board of Medical Examiners investigated him after multiple complaints but decided to take no action.

Getting cleared by the medical board did not end suspicion of Rinehart among law enforcement.

Perry Sherbaugh, chief of the Nehalem Bay Fire & Rescue District since 2009 and a police officer in Tillamook County for 17 years before that, says some officers pushed for the Oregon Department of Justice to investigate Rinehart, but nothing came of it.

Former employees also complained to the DOJ about Rinehart in 2011, but again, nothing came of those complaints.

"We know that the clinic prescribes a lot of pain medication, and we've seen overdoses related to it," says Tillamook County Sheriff Andy Long. He says it's impossible to know how much drug-related crime is tied to the Rinehart Clinic.

Rinehart says his chief nemesis is Tillamook County District Attorney Bill Porter. Law enforcement sources say Porter has made Rinehart's prescribing practices a focus of his attention. Porter declined to be interviewed for this story.

The DEA, however, is the most formidable adversary Rinehart has yet faced.

The federal agents who showed up at the Rinehart Pharmacy on May 16 were armed with a search warrant that, for the first time, publicly documented suspicions that had long hovered over the clinic.

In its warrant, which is based in part on information an anonymous former pharmacy staffer provided, the DEA cited "the prescribing practices of the physicians at the Rinehart Clinic, including early filling of prescriptions, questionable medication combinations, out-of-state patients and a high volume of prescriptions written." (Rinehart is the only full-time doctor at the clinic.)

Rinehart calls those concerns "ridiculous." He claims that he has significantly reduced the amount of pain medication he has prescribed over the past year.

Still, in the face of the federal investigation, he's defiant.

"Hardly anybody else on the coast will treat these patients," he says.

He says he has urged his chronic-pain patients to find other methods of coping, such as better diets, more exercise and greater social engagement.

Rinehart says the crackdown on prescription opiates is in some ways misguided.

"Some people just don't feel the treatment of chronic pain is appropriate," he says.

Rinehart says the crackdown on opiates is hypocritical given that only 2 percent of Americans are addicted to them while 30 percent have issues with alcohol.

He also notes that nonsteroidal anti-inflammatory drugs sold over the counter, such as Advil and Aleve, cause more than 16,000 deaths annually in the U.S., about the same number as prescription opioids.

"Where's the outrage about Aleve?" he asks.

On June 15, Rinehart made a rare trip to Portland to give a talk to a group of naturopaths about pain medication.

He cautioned his audience—not to quit prescribing pain meds, but to put their assets in trusts to protect themselves against lawsuits.

Some critics question whether part of Rinehart's support for pain medication is financial. Pain and addiction patients are loyal customers of his clinic, and with the clinic's ownership of a pharmacy and position adjacent to a nursing home, he's got a vertically integrated business.

Rinehart lives in a $1 million home on 1.4 ridgetop acres purchased by his grandfather. His 3,200-square-foot shingle-and-log home above Manzanita has a breathtaking view of the Pacific and Nehalem Bay.

But Rinehart insists his motivation has never been money. Rather, it is simply a different attitude about how to treat pain.

Rinehart has tried to retire—he stepped down as medical director when his clinic celebrated its 100th birthday last year, but the doctor hired to replace him didn't last. Rinehart retook the reins and is again searching for someone to take his place. One thing is for sure: The century-long run of a Rinehart heading the clinic will end with him. Rinehart's son works in the coffee business in Portland, and his daughter is an FBI profiler who works in Virginia.

His clinic also faces threats beyond the DEA investigation.

The Affordable Care Act has given previously uninsured patients—about 25 percent of Rinehart's clientele—more choices. And competition is growing. For years, there were few alternatives to Rinehart in the 49 miles between Seaside and Tillamook. But in 2012, Adventist Health, which runs the Tillamook Regional Medical Center, opened a clinic in Manzanita—next to the driveway leading to Rinehart's home.

Rinehart says he'll keep soldiering on. He'll do so alone. His wife of 30 years, who was a nurse at his clinic, recently filed for divorce. He plans to continue carrying on his family's mission, moving implacably like the Nehalem River, even if the tide shifts against him.

“Our goal is to be here for the next 100 years,” he says. “To take care of all of the people in need.”

THE PHARMACY

That's because they have been there before.

In 2010, the DEA and state officials shut down the Wheeler Pharmacy after determining that an employee was distributing pain pills without prescriptions.

When agents took inventory of the tiny pharmacy, they came up more than 18,000 tablets short of methadone and 2,600 tablets short of oxycodone, two opioid pain relievers. To put those numbers in perspective, Wheeler's population is 414.

The owner of the pharmacy at the time, Jeffrey Collett, was fined $15,000, and a technician went to jail. Collett did not respond to WW's questions.

Dr. Harry Rinehart was not named in that case, but the Wheeler Pharmacy operated in close affiliation with Rinehart's clinic. Many of Rinehart's patients filled their prescriptions there. Rinehart says he required pain patients to count their pills in front of him to show they weren't overconsuming or selling them. That's a policy he put in place after 2006, when the Oregon Board of Medical Examiners investigated (but didn't uphold) allegations that Rinehart's prescribing practices were leading to abuses by patients. BME investigations are not public record.

Some patients could not account for their pills—and so the pharmacy helped them out of a jam.

"Patients told me that if they were short [of pills], they could just walk into the Wheeler Pharmacy and get pills without even being charged," Rinehart says.

When the Wheeler Pharmacy closed, a new pharmacy, called the Nehalem Bay Pharmacy, opened next to the Rinehart Clinic. It soon failed after a technician was arrested there for stealing morphine.

In 2013, the Rinehart Clinic bought the Nehalem Bay Pharmacy. That allowed the clinic access to a federal program providing drugs at the government's deeply discounted cost—an attractive proposition for a money-losing clinic.

But the Rinehart Pharmacy soon fell afoul of the Oregon Board of Pharmacy for sloppy practices, including delivering a prescription to the wrong person and improperly disclosing an individual's confidential information. The Board issued a $5,000 fine on Oct. 31, 2013, forgivable if the pharmacy stays out of trouble for three years.

And then, last month, the DEA came back to town. NIGEL JAQUISS.

WWeek 2015