1. Caldwell County Narcotic Initiative
Ed Bujold, MD, Wilson Pace, MD, Jessica Huff MPH
Elizabeth W. Stanton, MSTC
Granite Falls, NC

2. Historical Perspective

3. Historical Perspective

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

5. 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

6. 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

7. 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

8. 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

9. 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

10. 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

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

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

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

14. 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

15. 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

16. 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

17. 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

18. 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