Chronic Pain InitiativeCCNC and Project Lazarus:
Chronic Pain and Community Initiative
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Community Care of North Carolina (CCNC), in conjunction with non-profit organization Project
Lazarus, is responding to some of the highest drug overdose death rates in the country through its
Chronic Pain Initiative (CPI). Goals Reduce opioid-related overdoses Optimize treatment of chronic pain Manage substance abuse issues (opioids)
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A set of interrelated programs designed to improve the medical care
received by chronic pain patients, and in the process, to reduce the
misuse, abuse, potential for diversion and overdose from opioid
medication.
Key program components:
Clinical Community FocusPrimary Care Physician Toolkit Take only your own medications
Emergency Department Toolkit Keep medications in a safe placeCare Management Toolkit Education on dangers of opioidsNetwork CPI Champion
What is the Chronic Pain Initiative?
Model is based on proper assessment, diagnosis, and treatment plan with Pain agreement as necessary
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Why are we looking at replication?
Evidence exists that the Wilkes County approach is changing conditions in ways
that will reduce misuse, abuse, diversion and overdose from prescription opioids.
Changes in how medical professionals manage chronic pain patients and monitor their prescription use.
Change in opioid prescribing policy and practice within ED of Wilkes Regional Medical Center
Increased access to Naloxone and understanding of when and how to use
Pill take-back days
Community awareness, coalition building for community education
Reduction in unintentional poisoning deaths, especially those stemming from
narcotics prescribed by providers based in Wilkes County
Unintentional Poisoning Deaths by County: N.C., 1999-2009
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Source: N.C. State Center for Health Statistics, Vital Statistics-Deaths, 1999-2009 Analysis by Injury Epemiology and Surveillance Unit
1999 - 2001
Unintentional Poisoning Deaths by County: N.C., 1999-2009
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Source: N.C. State Center for Health Statistics, Vital Statistics-Deaths, 1999-2009 Analysis by Injury Epemiology and Surveillance Unit
2002 - 2005
Unintentional Poisoning Deaths by County: N.C., 1999-2009
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Source: N.C. State Center for Health Statistics, Vital Statistics-Deaths, 1999-2009 Analysis by Injury Epemiology and Surveillance Unit
2006 - 2009
Poisonings on the Rise
5.56.8
8.5 8.810.4 10.5 10.4
11.5 11.810.4
0.0
2.0
4.0
6.0
8.0
10.0
12.0
14.0
2001 2002 2003 2004 2005 2006 2007 2008 2009 2010
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*Source: NC. State Center for Health Statistics; annually generated poisoning report for Project Lazarus. ** Mortality rates calculated from bridged population estimates (2001-2009) and 2010 US Census counts.
Mor
talit
y ra
te/1
00,0
00 p
opul
ation
NC mortality rates, unintentional and undetermined intent poisonings, 2001-2010
Problem Acute in Wilkes County
8.2 8.510.4 10.5
10.8 11.5
23.9
8.2
24.526.9 28.3
41.6
46
6.7 7.1 8 9.9
05
101520253035404550
2003 2004 2005 2006 2007 2008 2009
NC
Wilkes
USA
9
Mor
talit
y ra
te/1
00,0
00 p
opul
atio
n
Source: NC SCHS, August 2009
Unintentional and undetermined intent poisoning mortality ratesWilkes County, NC 2003-2009
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NC Cost of Hospitalizations for Unintentional Poisonings
Average cost of inpatient hospitalizations for an opioid poisoning*: $16,970
Number of hospitalizations for unintentional and undetermined intent poisonings**: 5,833
Estimated costs (2008): $98,986,010Does 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, 1/19/2011
100 North Carolina counties # Cost
Patients with >12 opioid scripts and >=10 ED visits in past 12 months
2,256
ED Visits (average per visit cost $2,610.00) $5,881,160
>12 narcotics 16,172
Medicaid Network Patient Case Management
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Controlled Substances/Overdoses
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Opioids a Rising NC Problem
t
*Source: NC State Center for Health Statistics; annually generated poisoning report for Project Lazarus
Narcotics causing or contributing to fatal unintentional and undetermined intent poisonings*: N.C. residents, 2001-2010
138152
89
170140
179
220
176
231
339
277 272
365
287308
267
347
313
243
474
286
229
513
235
160
510
179
0
100
200
300
400
500
600
Cocaine & Heroin Other and SyntheticOpioids
Methadone
2001200220032004200520062007200820092010
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Key Ingredients in Chronic Pain Initiative
Establishment (or prior existence) of a community coalition that is able to develop and implement effective strategies to reduce substance use
A sense of urgency among local actors who have influence
Dedicated manager of the coalition with skills in process and content
Appropriate strategy for achieving a change in prevailing medical practice re: treatment of chronic pain patients (PCP and ED locations)
Tailored to local conditions
Includes education on the extent of the problem in the community and the role of providers in limiting supply and opportunities for diversion
Includes useful tools that providers can adopt (e.g., Medication Agreements, guidelines for proper script writing)
Explicit recommendations for hospital policies that limit dispensing of narcotics (especially to ED patients)
Take advantage of leverage points in larger environment (e.g., CSRS, Medicaid lock-in policy)
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Makes effective use of various partners in carrying out strategies including but not limited to:
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
Law enforcement
Schools
Behavioral Health, Prevention and Treatment Programs and Organizations
Key Ingredients in Chronic Pain Initiative
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Contents of the Toolkit
General information o Managing chronic pain
o Proper prescription writing
o Precautions
Tools for managing chronic pain patientso Universal Precaution for Prescribing and Algorithm for assessing and managing pain
o Pain Treatment Agreement
o Format for progress notes
o Medication flowsheet
o Personal care plan
o Prescriber and Patient education materials
o Screening Forms and Brief Intervention
o Naloxone Prescribing
o Controlled Substance Reporting System (CSRS)
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Primary Care Tool Kit
• Physician toolkit for treating chronic pain patients
• Encourage the use of Pain Treatment Agreements with chronic
pain patients
• Encourage use of Provider Portal
• Encourage use of Controlled Substance Reporting System
(CSRS)
• Encourage the assignment of pharmacy home for chronic pain
patients lock-in program
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Emergency Department Tool Kit
• Care management for pain patients visiting ED
• ED policy that restricts the dispensing of narcotics
• Encourage the Use of the CSRS by ED physicians
• Encourage the Use of Provider Portal in the ED
• Identify Chronic Pain Patients and Refer for Care Coordination
based on ED assessment
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Care Management Tool Kit
Provide support to ED identification of chronic pain patients- referrals to PCP or specialty services
Provide care management for patients identified by PCP practice as CPI patient; consider pharmacy lock-in program
Ongoing care management for Medicaid patients with narcotic prescriptions above threshold pain patients via TREO data
Educate PCPs and providers in utilization of Chronic Pain Tool Kit
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Project Lazarus Results1. Lower Risk in the Community 2. Similar Benefit to Patients
3. Improved Risk : Benefit
15%
69%
15%
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Can coalitions help reduce Rx drug abuse?
Counties with coalitions had 6.2% lower rate of ED visits for substance abuse than counties with no coalitions (could be due to random chance)
However, counties with a coalition where the health department was the lead agency had a statistically significant 23% lower rate of ED visits (X2=2.15, p=0.03) than other counties
In counties with coalitions 1.7% more residents received opioids than in counties without a coalition.
Coalitions may be useful in reducing the harms of Rx drug abuse while improving access to pain medications.
More professional coalitions may have a greater impact on reducing Rx drug harms.
Data Sources: NC Health Directors Survey, NC DETECT (2010), CSRS (2008-2010)
22Source: CCNC 2011
LegendAccessCare Network Sites Community Care Plan of Eastern CarolinaAccessCare Network Counties Community Health PartnersCommunity Care of Western North Carolina Northern Piedmont Community CareCommunity Care of the Lower Cape Fear Northwest Community CareCarolina Collaborative Community Care Partnership for Health ManagementCommunity Care of Wake and Johnston Counties Community Care of the Sandhills Community Care Partners of Greater Mecklenburg Community Care of Southern PiedmontCarolina Community Health Partnership
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Contact
Dr. Mike Lancaster [email protected]
Fred Wells Brason II [email protected]
www.communitycarenc.org www.projectlazarus.org