SAN ANTONIO – A primary care initiative combining patient pledges with random pill counts and urine screens significantly reduced prescription narcotics diversion in North Carolina’s rural Caldwell County.
Courtesy of Myra LongDr. Ed Bujold worked with law enforcement and social service agencies to create a registry that helped reduce by 300% the number of prescription narcotics seizures in one rural North Carolina county.
As part of the program, most primary care patients with chronic, nonmalignant pain sign a contract agreeing to those measures – and pledging not to doctor-shop for narcotics – prior to receiving their prescriptions, explained Dr. Ed Bujold, a family physician in the Caldwell County town of Granite Falls who helped spearhead the initiative.
Physicians in the western North Carolina county began to use the contracts in 2007, which coincided with a 300% drop in prescription narcotics seizures by county law enforcement between 2005 and the end of that year.
"I believe most of the impact on the 300% decrease took place in [2007]," Dr. Bujold said at the Society of Teachers of Family Medicine Conference on Practice Improvement.
There’s been no evidence the measures keep patients who truly need narcotics from getting them, he added.
In fact, patients "are in complete agreement with this. I have had several say, ‘I am so thankful you are doing this. I don’t want these drugs to go out to places they are not supposed to be,’?" Dr. Bujold said.
Dr. Bujold said he is also more confident prescribing Percocet (oxycodone and acetaminophen), OxyContin (oxycodone), Vicodin (hydrocodone and acetaminophen), and other narcotics to the few hundred chronic pain sufferers among his roughly 3,500 patients. A survey found other primary care physicians participating in the initiative are as well.
"I feel very comfortable treating patients now, because I know that I am not dealing with the riffraff," Dr. Bujold said. "This system pretty much takes them out of the picture."
The idea was born in 2006 after a church service, when the Caldwell County sheriff approached Dr. Bujold, a fellow parishioner.
The sheriff confided in him that prescription narcotics threatened to become the county’s main drug problem, ahead of methamphetamine and cocaine. Local law enforcement officials recently had found two houses stocked with prescription narcotics for street sale, he added.
A few local physicians had been too trusting, prescribing narcotics "without even thinking some might end up on the street," Dr. Bujold explained.
Over the next year, Dr. Bujold, two county narcotics officers, a pharmacist, a community nurse, and the regional director of Community Care of North Carolina worked on a solution.
The contract was its centerpiece, downloaded from the American Society of Anesthesiologists Web site. Patients who sign it pledge to get their narcotics from one physician and one pharmacy, and submit to random pill counts and urine drug screens.
Once the plan was in place, the nurse visited local primary care practices to explain the diversion problem and contract initiative.
At the same time, North Carolina created an online narcotics registry accessible to doctors and pharmacists.
"It closed the loop for us. If we have somebody who comes in as a new patient, and their story sounds a little fishy, we can go to the narcotics registry," explained Dr. Bujold. "If they’re getting prescriptions from 10 physicians and 5 pharmacists, we know right away that this is not somebody we are probably going to work with."
By 2008, narcotics officers reported cocaine and methamphetamine were again the main drug problems in Caldwell County. There were also reports that drug-seeking patients were leaving the county.
Currently, around 90% of local physicians use the contracts, and patients submit to urine screens and pill counts about twice a year when their names come up on a randomly generated list.
Not finding narcotics in the urine of patients prescribed narcotics is a red flag. Marijuana detection is, too, because it’s not legal in North Carolina for medical purposes, though "we try to make a decision based on the individual’s circumstances," Dr. Bujold said.
If patients violate their contract, they are cut off from narcotics, something that happens about twice a month in Dr. Bujold’s practice, he said.