Project Lazarus: Community-Based Overdose

Prevention

April 10-12, 2012 Walt Disney World Swan Resort

Accepted Learning Objectives: 1. Describe how Project Lazarus collaborates with community agencies to achieve a coordinated overdose prevention program. 2. Identify the five key components of Project Lazarus. 3. Explain the process for implementing Project Lazarus-type initiatives in other communities.

Disclosure Statement

•  Chaplain Fred Wells Brason II – Project Lazarus - Purdue Pharma

•  Unrestricted Educational Grants •  Consultation

•  Naloxone nasal atomizers – After market add on

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www.projectlazarus.org  Fred  Wells  Brason  II  

The  State  of  Prescrip=on  

Drug  Abuse  in  NC

"Project Lazarus believes that communities are ultimately responsible for their own health and that

every drug overdose is preventable. We are a secular, non-profit organization that provides

technical assistance to community groups and clinicians throughout North Carolina and beyond.

Using experience, data, and compassion we empower communities and individuals to prevent

drug overdoses and meet the needs of those living with chronic pain."

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“Reducing supply, demand, diversion and harm.”

Prepared by Project Lazarus with funding from an unrestricted educational grant from PPLP, NED101536 and NCCN.

1. Community knowledge;

Coalition building

2. Epidemiology

3. Prevention:

4.Rescue

5. Program Evaluation:

3

source  +  more  info  at  projectlazarus.org  

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Project Lazarus: Step 1.Community Knowledge and Coalition Building

Community Awareness

Data Collection

Community Assessment

Community Coalition Building

Strategic and

Action Planning

Implemen-tation

Evaluation

Community Awareness

Community Forums

Community Workshops Community Coalitions

1. Community knowledge;

Coalition building

2. Epidemiology

3. Prevention:

4.Rescue

5. Program Evaluation:

3

Project Lazarus. Step 2 – Epidemiologic Monitoring

SCHS-­‐State  Center  for  Health  Sta=s=cs;  OCME-­‐Office  of  the  Chief  Medical  Examiner;  NCDETECT  –  North  Carolina    Disease  Event  Tracking  and  Epidemiologic  Collec=on  Tool;  CPC-­‐Carolina  Poison  Center;  CSRS-­‐Controlled  Substances  Repor=ng  System.  

Fatal Events Death Certificates –

SCHS Medical Examiner Reports - OCME

Availability of Prescribed Opioids

Outpatient dispensed controlled substances - CSRS

Non-Fatal Events Hospital data – SCHS

Emergency Dept. data – NCDETECT

Poison Center calls - CPC

Doctor Shopping Decreases in NC

Source: NC CSRS

NC Controlled Substance Reporting System

County Registered Prescribers/Pharmacists

NC State 28.00 %

Wilkes 70.00 %

Community Pride

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Unintentional Poisoning Deaths by County: N.C., 1999-2009

4/3/12 17

Prepared by Project Lazarus with an unrestricted educational grant from Purdue

Pharma LP, NED101356

Source:  N.C.  State  Center  for  Health  Sta=s=cs,  Vital  Sta=s=cs-­‐Deaths,  1999-­‐2009  Analysis  by  Injury  Epidemiology  and  Surveillance  Unit  

Unintentional & undetermined intent poisoning mortality rates by year: U.S. and N.C., 2003-2010*

www.projectlazarus.og 18 4/3/12

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*Sources: US, WISQARS, accessed 01/24/2012; NC and Wilkes County, NC, NC-State Center for Health Statistics, accessed 10/24/2011

Narcotics causing or contributing to fatal accidental drug overdoses*: North Carolina 2000-2010

*Source: NC DHHS State Center for Health Statistics, October 2011

4/3/12 www.projectlazarus.org 19

The Scope of the Problem

Source: Wilkes Co. Health Department; NC SCHS; CDC Wonder

The areas with the highest percent getting opioids also have high poverty.

Source: NC CSRS and US Census

Cost of Hospitalizations for Unintentional Poisonings: NC, 2008

•  Average cost of inpatient hospitalizations for an opioid poisoning*: $16,970.

•  Number of hospitalizations for unintentional and undetermined intent poisonings**: 5,833

•  Estimated costs in 2008: $98,986,010

Does not include costs for hospitalized substance abuse

*Agency for Healthcare Research and Quality ** NC State Center for Health Statistics, data analyzed and prepared by K. Harmon,

Injury and Violence Prevention Branch, DPH, 01_19_2011

Prepared  by  Project  Lazarus  through  an  unrestricted  educa=onal  grant  from  Purdue  Pharma  LP:  NED101356  

The  Ten  Most  Frequently  Cited  Drugs  in  ED  Visits  Due  to  Uninten8onal  Poisonings,  NC  DETECT  :  2010*  

Source:  NC  DETECT,  2009  Analysis  by  Injury  Epidemiology  and  Surveillance  Unit  

*Provisional  data  Jan-­‐June:  final   diagnoses  may  take  up  to  three  months.  

Neo-natal Abstinence Syndrome

•  Newborns with chemical dependence withdrawal issues – Wilkes County 2010 10% of newborns

•  NOT “OXYTOTS;” •  NOT “ADDICTED BABIES”

Hospitalizations Associated with Drug Withdrawal in Newborns, 2004-2008

Birth Rates Per 100,000

Source:  N.C.  State  Center  for  Health  Sta=s=cs,  2004-­‐2008  Analysis  by  Injury  Epidemiology  and  Surveillance  Unit  

Rates of Hospitalizations Associated with Drug Withdrawal Syndrome in Newborns per 100,000

Live Births, 2004-2008

Source:  N.C.  State  Center  for  Health  Sta=s=cs,  2004-­‐2008  Analysis  by  Injury  Epidemiology  and  Surveillance  Unit  

113%  Increase  

Type of Payment Associated with Drug Withdrawal Syndrome in Newborns per 100,000

Live Births, 2004-2008

Source:  N.C.  State  Center  for  Health  Sta=s=cs,  2004-­‐2008  Analysis  by  Injury  Epidemiology  and  Surveillance  Unit  

$35  Million  in  Hospital  Charges*  

*Charges do not reflect what the care actually cost the hospital or what the hospital received in payment.

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Source of illicit drugs in Americans age 12 or older: 2010*

Bought  from  friend  or  rela=ve,  11.4%  

Took  from  friend  or  rela=ve,  4.8%  

Some  other  way,  4.2%  

Bought  from  drug  dealer  or  other  stranger,  4.4%  

*Source:  2010  Na=onal  Survey  on  Drug  Use  and  Health.  SAMHSA  hbp://www.samhsa.gov/samhsaNewsleber/Volume_19_Number_3/surveyshows.aspx  

From  mul=ple  doctors,  2.1%  Wrote  fake  prescrip=on,  0.2%  

2010  NATIONAL  SURVEY  ON  DRUG  USE  AND  HEALTH  SHOWS  RISE  IN  ILLICIT  DRUG  USE.    

In  2010,  22.6  million  Americans,  age  12  or  older,  (8.9%  of  the  popula=on)  reported  having  used  an  illicit  drug  in  the  past  12  months.    

The  percentage  of  youths,  ages  18  to  25,  who  reported  using  drugs  for  non-­‐medical  reasons  increased  from  19.6%  in  2008  to  21.5%  in  2010.                                                            

In  2010,  23.1  million  Americans,    age  12  or  older,  needed  treatment  for  substance  abuse  but  only  2.6  million  (11.2  %)  received  treatment.    

Diversion C

ontrol

Drug  Terminator  

Pill  Take  Back  

Permanent  Pill  Collec=on  

“EASY BUTTON” to life problems

1. Community knowledge;

Coalition building

2. Epidemiology

3. Prevention:

4.Rescue

5. Program Evaluation:

3

The Response: Chronic Pain Initiative Led by NC Medicaid to work with medical community

• Public health department – multiple strategies

• County Medical Director – to reach physicians and ED

• Medical providers – to change their own practice and educate other providers

• Pharmacist – to other pharmacies in community

• Behavioral Health, Prevention and Drug Treatment Programs

• Encourage use of PMP Program

•  Physician toolkit on pain and opioids •  Pharmacy home •  Case management for pain patients and ED •  Restricted ED narcotics policy* •  Use of Controlled Substance Reporting

System •  Support group for pain patients •  Mental health collaboration •  Promoting drug treatment and

buprenorphine •  Community education

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Wilkes County Chronic Pain Initiative

EVALUATION Doug Easterling, Ph.D.

Associate Professor and Department Chair Department of Social Sciences and Health Policy

Division of Public Health Sciences Wake Forest University School of Medicine

Medical Center Blvd. Winston-Salem, NC  27157

Y. Montez Lane Jessica Richardson

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Emergency Department

•  Non-narcotic pain medication for “frequent fliers.” •  Prescriptions for narcotic or sedating medications

that have been lost, stolen or expired will not be refilled in the Emergency Department

•  Referrals to Primary Care Providers Accepting New Patients.

•  North Carolina Controlled Substances Reporting System, checked for any prescription for a controlled substance

•  Prescriptions necessary only in limited quantities

Conclusions continued •  Most providers reported that CPI led to improved CP

policies & procedures in their practices •  Providers perceive pain agreements to improve

patient behavior, especially in use of single pharmacy, PCP

•  Some discomfort remains in treating CP w/ opioids •  “Patients are more satisfied because the feel they're

validated having pain. If adhering to the agreement, don't have to feel guilty asking for pain meds.”

•  “Improved perceptions among patients of how they need to contribute to their own plan/agreement. “

Res

pond

ing

Med

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Pra

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ites

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Cherokee Graham

Swain

Clay Macon Jackson

Haywood

Madison Buncombe

Henderson McDowell

Rutherford Polk

Burke

Cleveland

Watauga

Caldwell Alexander

Catawba Lincoln Gaston

Ashe Wilkes

Alleghany Surry

Yadkin

Iredell

Mecklenburg Union

Stanly Cabarrus Rowan

Davie

Stokes Forsyth

Davidson

Anson

Rockingham

Guilford

Randolph

Montgomery Richmond

Caswell

Chatham

Orange

Person

Lee Moore

Hoke Scotland

Robeson

Cumberland

Harnett

Wake

Vance

Franklin

Warren

Johnston

Sampson

Bladen

Columbus Brunswick

Pender

Duplin

Wayne

Wilson Nash

Halifax Northhampton

Edgecombe

Pitt Greene Lenoir

Jones Onslow Carteret

Craven Pamlico

Beaufort Hyde Martin

Bertie Hertford

Gates

Washington Tyrrell Dare

Alam

ance Durham Granville

New

Hanover

Chow

an

a r

NC Medical Board NC Medical Society NC College of Emergency Physicians

1. Community knowledge;

Coalition building

2. Epidemiology

3. Prevention:

4.Rescue

5. Program Evaluation:

3

Prescriber Education

“The goals of Project Lazarus are consistent with the Board’s statutory mission to protect the people of North Carolina.

The Board therefore encourages its licensees to abide by the protocols employed by Project Lazarus and to cooperate with the program’s efforts to make naloxone available to persons at risk of suffering drug overdose.”- August 2008

Operation OpioidSAFE

MAJ Anthony Dragovich MD Medical Director, Pain Medicine

Ft. Bragg, NC

 Opera=on  OpioidSAFE  is  a  novel  provider,  pa=ent  and  community  educa=on  program  with  the  added  advantage  of  lay  person  diagnosis  and  

reversal  of  opioid  overdose.    

1. Community knowledge;

Coalition building

2. Epidemiology

3. Prevention:

4.Rescue

5. Program Evaluation:

3

Project Lazarus: Step 5. Program Evaluation

Process Evaluation Evaluate Chronic Pain

Initiative Monitor opioid prescribing

policy changes in ED Assess availability/use of

Buprenorphine and other substance abuse treatment

Monitor willingness of family or peers to use naloxone rescue kits in community.

Assess frequency of use of overdose plan template by Project Lazarus kit recipients.

Outcome Evaluation Changes in unintentional poisoning mortality. Changes in ED or hospital treatment of substance abuse and unintentional poisonings. Changes in prescribing patterns of controlled substances by local MDs. Changes in patterns of where victims of fatal overdoses obtained their prescribed opioids within 6 months of death.

Project Lazarus Results 1. Lower Risk in the Community 2. Similar Benefit to Patients

3. Improved Risk:Benefit

www.projectlazarus.org

15%    

71%    Project Lazarus and CPI did not decrease

the percent of residents receiving an opioid in Wilkes County.

www.projectlazarus.org  

Feb. 4, 1980 – August 12, 2006

STEPS Reviewed •  Addressing by Assessing Issue (Awareness) •  Initiate Chronic Pain Initiative •  Mobilize around Issue (Coalition)

– Community forum – Coalition capacity building –  Strategic Planning

•  Develop Action(s) (Prevention, Rescue, Treatment)

•  Explore and obtain resources •  Implementation

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Individual Physical

Psychological Social

Spiritual

Environmental Situation

Family

Religion Community

Peers School

Social Structures

Economic Conditions

Prejudices Employment Opportunities

Society

* Adapted from Carl Leukefeld, University of Kentucky July 2006

Youth

Civic Human Service

Military

Medical Local Gov’t

Deliverables: CCNC and Project Lazarus •  Chronic Pain Initiative

–  Prescriber Toolkit –  Care Manager Toolkit –  Emergency department Toolkit –  Training, Technical Assistance

•  Community Awareness (data – presentations – workshops – coalition building)

•  CME –  CPI –  Proper Prescribing –  CSRS

•  Pharmacist CE •  Law Enforcement Diversion Training •  Pill Vaults and Disposal •  Faith community, Business, Industry, Civic

and Human Service Organizations

Community Education

Community Education

Stakeholders Stakeholders Stakeholders

Community Forum Community Sectors

Project Lazarus – Coalitions

Steering Committee

Community Sector Workshops

Sector Committees – Objectives, Strategies, Tactics, Action Plans, Implementation

How to contact us

Fred Wells Brason II: fbrason@projectlazarus.org

Kay Sanford: kay.sanford@gmail.com Nab Dasgupta: nab@unc.edu Su Albert: salbert@wilkescounty.net

PROJECT LAZARUS www.projectlazarus.org

336.667.8100 •    55