Projectlazarus Fred Wells Brason II

1. 1

2. Project Lazarus - Mission Statement Project Lazarus provides expertise in managing a community-based educational and interventional program that�intends to reduce deaths among patients that are at increased risk�from abusing or misusing narcotics and dying from an accidental poisoning (unintentional drug overdose). 2

3. Designing Project Lazarus 3

4. LOCUS OF RURAL INTERVENTIONS 4

5. Step 1. Community awareness and coalition building Community organizers must know their communities. Communities must be made aware they have a problem, and Communities must be allowed to help formulate a response before they�ll support changes to the status quo. 5

6. 6 Substance Abuse Task Force Goals Increase community awareness Develop resource guide for treatment Identify barriers to prevention and treatment programs Identify gaps in available prevention and treatment programs Coordinate community efforts in response to problems of domestic violence, child abuse, automobile accidents, illness and death from substance abuse of alcohol, tobacco and drugs.

7. Wilkes coalitions working with Project Lazarus 7

8. 8

9. Designing Project Lazarus 9

11. Step 2. Epidemiologic Surveillance Broad spectrum of data on fatal and non-fatal overdoses Mortality Vital records Medical Examiner system Non-fatal overdoses Emergency Department Data on prescribing of controlled substances Practitioner access to patient prescribing profiles Public health access to anonymized data Global and local data Historical trends Current findings 11

12. Unintentional and undetermined intent poisoning mortality rates: NC, Wilkes County, 2003-2009 12 Since 2003, state fatal unintentional/undetermined intent poisoning rates (in blue) have increased in a stepwise fashion. Wilkes County rates, except in 2004, are at least 3 times higher than the state rates, and are currently among the top five county unintentional poisoning mortality rates in the country. Surry County saw in increase in poisoning mortality rates between 2003 (2 deaths) and 2006 (15 deaths). Unintentional/ undetermined poisoning mortality rates decreased in 2007 (based on 9 deaths) and rose again slightly in 2008 (10 deaths). Rates based on statistically small numbers, as has occurred in Surry County, must be interpreted with caution. However, since a reasonable number of deaths from poisonings should be zero, the number of deaths greater than one should be of concern, even though statistically small. The linear trend for Surry indicates a slow, but upward trend in mortality from preventable poisonings.Since 2003, state fatal unintentional/undetermined intent poisoning rates (in blue) have increased in a stepwise fashion. Wilkes County rates, except in 2004, are at least 3 times higher than the state rates, and are currently among the top five county unintentional poisoning mortality rates in the country. Surry County saw in increase in poisoning mortality rates between 2003 (2 deaths) and 2006 (15 deaths). Unintentional/ undetermined poisoning mortality rates decreased in 2007 (based on 9 deaths) and rose again slightly in 2008 (10 deaths). Rates based on statistically small numbers, as has occurred in Surry County, must be interpreted with caution. However, since a reasonable number of deaths from poisonings should be zero, the number of deaths greater than one should be of concern, even though statistically small. The linear trend for Surry indicates a slow, but upward trend in mortality from preventable poisonings.

13. 13 Unintentional deaths from poisonings, primarily due to drug overdoses, do not occur equally across our state. The counties with the highest mortality rates from unintentional poisonings are shown in the darkest shade of red. There are more counties with fatal drug overdoses in the western part of NC than in the piedmont or the eastern regions. Mitchell, Swain and Wilkes on this map have the highest rates. Unintentional deaths from poisonings, primarily due to drug overdoses, do not occur equally across our state. The counties with the highest mortality rates from unintentional poisonings are shown in the darkest shade of red. There are more counties with fatal drug overdoses in the western part of NC than in the piedmont or the eastern regions. Mitchell, Swain and Wilkes on this map have the highest rates.

14. Unintentional and undetermined intent poisoning mortality rates/100,000 population: Western NC Counties, 2008 Supported by Purdue Pharma L.P., Grant # NED101356 Prepared by Kay Sanford, September 2009, Revised January 2010 14 1. Poisoning rates calculated as deaths/100,000 pop., estimated from OSBM, April 2009 estimates. NC pop = 9,227,016 residents. 2. Mortality rates based on less than 10 deaths are statistically unstable and patterns may reflect random and not real changes. The following counties had less than 10 deaths in 2008: Alleghany, Ashe, Avery, Cherokee, Graham, Haywood, Madison, McDowell, Polk, Rutherford, Swain, Transylvania, Watauga and Yancey. 3. 2008 state unintentional/undetermined intent poisoning rate = 11.5. 2008 Western NC unintentional/undetermined intent poisoning rate = 18.2 4. The counties with the top 5 highest mortality rates in Western NC counties in 2008 are McDowell (29.2), Mitchell (37.4), Rutherford (39.9), Swain (42.9) and Wilkes (41.6). 1. Poisoning rates calculated as deaths/100,000 pop., estimated from OSBM, April 2009 estimates. NC pop = 9,227,016 residents. 2. Mortality rates based on less than 10 deaths are statistically unstable and patterns may reflect random and not real changes. The following counties had less than 10 deaths in 2008: Alleghany, Ashe, Avery, Cherokee, Graham, Haywood, Madison, McDowell, Polk, Rutherford, Swain, Transylvania, Watauga and Yancey. 3. 2008 state unintentional/undetermined intent poisoning rate = 11.5. 2008 Western NC unintentional/undetermined intent poisoning rate = 18.2 4. The counties with the top 5 highest mortality rates in Western NC counties in 2008 are McDowell (29.2), Mitchell (37.4), Rutherford (39.9), Swain (42.9) and Wilkes (41.6).

15. 15

16. Dispensed outpatient prescriptions for controlled substances rates/10,000 population: Western NC Counties, 2008 16 1. Prescription rates calculated as dispensed scripts/10,000 pop., estimated from OSBM, April 2009 estimates. NC pop = 9,227,016 residents. Prescription data from NC-CSRS, reported as of March 2009. 2. 2008 state outpatient prescriptions for controlled substances rate =17,522 scripts/10,000 population. Western NC rates for 2008 were 21,178 scripts per 10,000 population. 3. The top five counties in western NC counties with the highest prescription rates/10,000 pop in 2008 were Cherokee (25800), Haywood (22819), McDowell (23786), Swain (23681), and Wilkes (27384). 1. Prescription rates calculated as dispensed scripts/10,000 pop., estimated from OSBM, April 2009 estimates. NC pop = 9,227,016 residents. Prescription data from NC-CSRS, reported as of March 2009. 2. 2008 state outpatient prescriptions for controlled substances rate =17,522 scripts/10,000 population. Western NC rates for 2008 were 21,178 scripts per 10,000 population. 3. The top five counties in western NC counties with the highest prescription rates/10,000 pop in 2008 were Cherokee (25800), Haywood (22819), McDowell (23786), Swain (23681), and Wilkes (27384).

17. Top 10 Controlled Substances Outpatient Dispensing Rates: NC, 2008-2009* 2008 controlled substances Script rate/10,000 pop . 2009 controlled substances script rate/10,000 pop . 17

18. Comparison of substances causing fatal overdoses and outpatient dispensed controlled substances, North Carolina, 2008 Mortality data Controlled substances data 18

20. 20 The highest outpatient prescribing rates of controlled substances were in rural �not counties, predominantly in the western part of the state, along the eastern seaboard and in the southeastern corner next to South Carolina. Wilkes county rates are in the highest quartile; Surry in the second highest quartile.The highest outpatient prescribing rates of controlled substances were in rural �not counties, predominantly in the western part of the state, along the eastern seaboard and in the southeastern corner next to South Carolina. Wilkes county rates are in the highest quartile; Surry in the second highest quartile.

21. NC out-patient controlled substances prescription dispensing and accidental poisoning mortality rates by county 21

22. Where Pain Relievers Were Obtained Non-medical Use among Past Year Users Aged 12 or Older 2006 22 ## So if mostly from friends why should the Board worry ? #### So if mostly from friends why should the Board worry ? ##

23. Designing Project Lazarus 23

24. Chronic Pain Initiative Programs Northwest Community Care Network (Medicaid) -- 6 County 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 24

25. Step 3. Prevention Chronic Pain Initiative Goals Decrease ED utilization for chronic pain Decrease multiple prescribers and pharmacies Establish PCP and pharmacy homes Create alert system (policy initiative) Improve PCP chronic pain management Encourage pain clinic referrals Encourage co-management model for partnership with pain clinic 25

26. GOALS of Chronic Pain Initiative continued Reduce number of accidental poisonings Develop a reproducible, comprehensive approach to chronic pain management that may be duplicated by other Networks. Decrease costs 26

27. Wilkes County Chronic Pain InitiativeEVALUATION Doug Easterling Y. Montez Lane Jessica Richardson

28. Summary: Key Findings A community coalition in Wilkes County, North Carolina developed a Physician Tool Kit containing a model �Pain Agreement� and other �tools� that providers can use to improve the management of patients with chronic pain (e.g., algorithm for assessing and managing pain, format for progress notes, medication flowsheet). To promote uptake of the Toolkit, the Wilkes County Medical Director has to date met personally with providers in 15 of the 46 medical practices in the county. This study involved interviews with 14 providers (physicians, physician assistants, nurse practitioners) from 9 different practices who were introduced to the Toolkit prior to January 2009. 12 of the 14 providers interviewed for the study reported that they use a Pain Contract. Four of these providers began using Pain Agreements after being oriented to the Physician Toolkit. Other providers who had already been using Pain Agreements reported that they were now using them more frequently with chronic pain patients. The median provider uses the Agreement with 20 patients per month. Providers exposed to the Toolkit also reported more regular monitoring of the Controlled Substances Reporting System (CSRS). Providers reported only modest use of tools other than the Pain Agreement (e.g., progress notes, guidelines for writing scripts for pain medication, patient education materials) Providers report that the Pain Agreement and other tools have led to clearer, more direct, and more comfortable interactions with patients, while also making it easier to stop prescribing opioids when the Agreement is violated. The number of death from prescription drug overdose has decreased slightly in Wilkes County since first of year. A larger change is that overdose deaths are now much more likely to result from prescriptions written by providers outside the county.

29. Provider Perceptions of Patient Change Comments: �Patients are more satisfied because the feel they're validated having pain. If adhering to the contract, don't have to feel guilty asking for pain meds.� �Patients seem happier since they're given the boundaries up front. More satisfied by knowing what to expect.� �Patients are made to be more honest about the issue once it's documented.� �Improved perceptions among patients of how they need to contribute to their own plan/contract. � �Patients realize contract is binding and cannot veer from it.�

30. Wilkes County NC 2009 Overdoses 30 Deaths (actual, 31) 23 had prescription history 7 had no prescription history 17 had prescriptions from out of county MD 75% 2009 versus 18% 2008 6 had prescriptions from in county MD (First half of year) 23 had prescription within two weeks that was related to death 7 had no relation to death

31. Overdoses cont. 19 Males/12 Females; Average age 39 16 Oxycodone 2 Hydrocodone 2 Fentanyl 5 Methadone 1 Mixed 1 Morphine 1 Heroin 2 Alcohol

32. Designing Project Lazarus 32

34. Step 4. Rescue Project Lazarus Prevention efforts -- not always sufficient. Rescue is a proactive response to the failures of drug overdose prevention Rescue focuses on changing the practice of medicine (prescribing of an antidote for opioid-induced respiratory depression) educating people to be better patients changing community attitudes towards the misuse and abuse of opioids. Access to Treatment 34

35. The antidote to fatal respiratory depression: Naloxone HCL (Narcan�) Mu-opioid receptor antagonist Can�t get high from it Decades of experience Uses: anesthesia & emergency Quick acting, works 30-90 minutes. Generic (cheap?) Delivered via injection (IM, SC, IV) or nasal 35

36. NC Medical Board Statement �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.� 36

37. Designing Project Lazarus 37

38. Step 5. Evaluation of Project Lazarus Process Simplicity in clinical setting and community Flexibility to clinicians and participants Data quality from pilot, vital records, CSRS Acceptability � LMDs and participants Representativeness of participants vs. decedents Timeliness of responses to LMDs and participants Monitoring changes of ED narcotics policies Availability/use of Buprenorphine and other substance abuse treatment 38

39. Project Lazarus Evaluation, cont. Outcome � surveillance and participant follow-up Accidental poisoning deaths ED visits for substance abuse and poisoning Project Lazarus interviews every 3 months Project Lazarus opioid overdoses Project Lazarus uses of naloxone rescue kit Participant lives saved Prescriptions for opioids in Wilkes Co. Prescriptions for buprenorphine in Wilkes Co. 39

40. Project Lazarus Firsts First naloxone program in the South First community based approach First introduction into general medical practice First focus on prescription drugs First to focus on pain patients First time approved by a medical board 40

41. What we�d like to do next� Permanent drug take-back site Promote/give away lock boxes Pharmacist CEUs on diversion and PMP Continued physician CMEs Broader regional coalitions Military populations 41

42. Further Collaboration US Army: Operation OpioidSAFE Womack Army Medical Center at Ft. Bragg, NC Project Lazarus model Pain clinic and general practice doctors Naloxone rescue, patient and peer education American Pain Foundation (APF): PainSAFE Education regarding opioid prescribing Disposal information Naloxone rescue medication Western North Carolina MAHEC 42

43. Contact Information 336.667.8100 Fred Wells Brason II, President/CEO fbrason@projectlazarus.org Nabarun Dasgupta, MPH VP Policy nab@email.unc.edu Kay Sanford, MSPH VP Research and Evaluation kay.sanford@gmail.com Su Albert, MD, VP Medical Director salbert@wilkescounty.net 43