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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
4
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."
5
“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
8
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
10
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
Mo
rta
lity
Ra
te: D
ea
ths/
100,
000
po
pu
latio
n
*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.
52
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
38
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
17
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
ical
Pra
ctic
e S
ites
21
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: [email protected]
Kay Sanford: [email protected] Nab Dasgupta: [email protected] Su Albert: [email protected]
PROJECT LAZARUS www.projectlazarus.org
336.667.8100 • 55