Caldwell County Narcotic Initiative Ed Bujold, MD, Wilson Pace, MD, Jessica Huff MPH Elizabeth W. Stanton, MSTC Granite Falls, NC www.bujoldmd.com bujold@embarqmail.com

Historical Perspective

Historical Perspective

National Statistics In every age group, death rate for men > women Highest mortality: 45-54 years of age 40% of narcotic prescriptions – primary care practitioners 3% of population receive long term opioids for chronic non cancer pain

Unintentional Over Dose Death in West Virginia, 2006 Highest death rate in the nation 95% had one or more indicators of drug or substance abuse Low level of education and poverty Opioids – implicated in 93% of deaths Methadone

Methadone The 17th most prescribed narcotic in North Carolina Number one cause of accidental overdose among unintentional deaths Oxycontin Third party payers, Medicare, Medicaid - financial pressures Peak pain relief – 5 to 6 hours Half life – 18 to 24 hours

The Problem Prescription narcotics and anxiolytics were as big as cocaine and methamphetamine as drugs of choice for abuse Two houses in Lenoir, NC were virtual pharmacies stocked with prescription drugs for diversion

The Problem Certain physicians in the area were known by the narcotic officers in the county as an easy “touch” Prescription drug diversion created several layers of community dysfunction starting in 7th and 8th grade

The Sheriff of Caldwell County Increasing frustration with social and law enforcement problems tied to diversion of prescription drugs Lack of understanding on the part of law enforcement officials as to why our medical community would flood the county with these drugs

Pain Management Community in the United States Chronic nonmalignant pain in the United States is undertreated Many patients suffer from their chronic pain due to lack of access to appropriate treatment centers Prejudice in the medical community

Clinical Guideline for Narcotic Use Physician/patient education Pain management contract Random urine drug screen and pill counting State wide narcotic registry

Community Care of North Carolina CCNC is a learning community Network in place Community health nurse with presence in the community of physicians

Task Force Director of regional CCNC network Two county narcotic officers CCNC community health care nurse Pharmacist/Physician Assistant Dr. Ed Bujold

Implementation Process Developing a usable clinical guideline, which is practical and applicable to busy primary care offices Buy-in from the primary care physicians (PCP) Dissemination of the guideline within the county PCP Community

Pre and Post Implementation Survey More confident in managing chronic pain Management of chronic pain improved Random urine drug screens Drug contract use State narcotic registry 66% State wide use of narcotic registry was 17%; state narcotic registry use in Caldwell County was 61% post implementation of the guideline

The Rest of the Story Between 2005 and 2007, 300% decrease in narcotic pills confiscation by law enforcement personnel Several anecdotal reports of patients leaving Caldwell County Partnership forged between doctors and law enforcement Cocaine, methamphetamines and heroine

The Future The FDA’s Risk Evaluation and Mitigation Strategy (REMS) Opioid makers provide training for health care providers and education material for patients State of Washington  patients will be asked to fill out a confidential, computerized assessment questionnaire at the start of therapy as well as after each visit Access issues

The Lazarus Project Wilkes County, North Carolina Developed out of the regional CCNC network Providers education packet Patient education packet with video Nasal naloxone prescriptions for patients Recognizing symptoms and signs of accidental narcotic overdose