Who is Project Lazarus?

Preventing opioid poisonings Promoting responsible pain management Fred Wells Brason II fbrason@projectlazarus.org Non-profit organization Who is Project Lazarus? Provides training and technical assistance Using experience, data, and compassion we empower communities and individuals to prevent drug overdoses and meet the needs of those living with chronic pain Believes that communities are ultimately responsible for their own health and that every drug overdose is preventable. Prescription Drug Misuse Overdose Defined: Accidental Poisoning Unintentional Overdose Overdose WHO? Patient misuse Family/Friends sharing to self medicate Recreational User Substance Use Disorder/Treatment/Recovery 1

CDC Policy Impact: Prescription Painkiller Overdoses Source: CDC-www.cdc.gov/homeandrecreationalsafety/rxbrief/ source + more info at projectlazarus.org 6 2

Unintentional Poisoning Mortality Rates: North Carolina, 2001-2011 Crude rates per 100,000 person-years Citation: North Carolina State Center for Health Statistics. NC Health Data Query System. Retrieved April 24, 2013 from http://www.schs.state.nc.us/schs/data/query.html. Data Attribution and Disclaimer: NC DHHS/DPH NC DETECT ED visit data were made available for this presentation by the NC DETECT Data Oversight Committee. The NC DETECT Data Oversight Committee includes representatives from the North Carolina Division of Public Health in the Department of Health and Human Services, the Carolina Center for Health Informatics in the Department of Emergency Medicine at the University of North Carolina at Chapel Hill, and the North Carolina Hospital Association. The NC DETECT Data Oversight Committee and NC DETECT do not take responsibility for 7 scientific validity or accuracy of the methodology, statistical analysis, results, or conclusions presented. Leading Causes of Injury Deaths (by Number of Deaths, All Ages, North Carolina Residents: 2012 $ ) Unintentional Motor Vehicle Crashes Suicides 1,185 1,242 Unintentional Poisoning 1,101 Unintentional Falls 900 Unintentional, Other & Unspecified* 739 Homicides 546 183 Unintentional Suffocation 93 Unintentional Drowning Total Deaths = 5,989 * Unintentional Other and Unintentional Unspecified are two separate categories. Other comprises several smaller defined causes of death, while Unspecified refers to unintentional deaths that were not categorized due to coding challenges. Source: NC State Center for Health Statistics, $ Provisional Death file 2012; Analysis by Injury Epidemiology and Surveillance Unit 3

CDC Policy Impact: Prescription Painkiller Overdoses Source: Substance Abuse and Mental Health Services Administration. Results from the 2010 National Survey on Drug Use and Health: volume 1: summary of national findings. Rockville, MD: Substance Abuse and Mental Health Services Administration, Office of Applied Studies; 2011. Available from URL: http://oas.samhsa.gov/nsduh/2k10nsduh/2k10results.htm#2.16. Source: CDC-www.cdc.gov/homeandrecreationalsafety/rxbrief/ EASY BUTTON to life problems What is being done 4

Project Lazarus Model Project Lazarus Model Addiction Treatment Harm Reduction Pain Patient Support Community Education Public Awareness Coalition Action Data & Evaluation Diversion Control Provider Education Hospital ED Policies The Project Lazarus model can be conceptualized as a wheel, with three core components (The Hub) that must always be present, and seven components (The Wheel) which can be initiated based on specific needs of a community. THE HUB I. Public Awareness is particularly important because there are widespread misconceptions about the risks of prescription drug misuse and abuse. It is crucial to build public identification of prescription drug overdose as a community issue. That overdose is common in the community, and that this is a preventable problem must be spread widely. II. Coalition Action - A functioning coalition should exist with strong ties to and support from each of the key sectors in the community, along with a preliminary base of community awareness on the issue. Coalition leaders should also have a strong understanding of what the nature of the issue is in the community and what the priorities are for how to address it. 5

Community forums must be repeated to motivate the necessary stakeholders to take action. Community coalitions must be provided tools to make their own strategic plans and design locally appropriate interventions. THE HUB cont. Data and Evaluation Epidemiologic Profile of Unintentional Poisonings: NC Counties The early data that you will need includes certain health related information: Mortality ED/Hospitalizations Treatment admissions Prescriptions dispensed % Prescribers signed on to PDMP Epidemiologic Profile of Unintentional Poisonings: Cabarrus, Rowan and Stanly Counties, N.C. 6

Number of Annual Deaths Mortality rates per 100,000 residents A decade of fatal unintentional* poisonings: Cabarrus, Rowan and Stanly Counties, NC, 2000-2012 35 30 29 25 25 20 15 21 17 20 10 5 8 6 4 8 10 0 1 2000 2004 2008 2012 Cabarrus Rowan Stanly Unintentional* Poisoning Mortality Rates: Cabarrus, Rowan and Stanly Counties, NC- 2009-2012 25 21 20 19.2 15 15.1 16.5 10 10.4 11.2 State Average Rate, 11.8 5 0 Cabarrus Rowan Stanly 2009 2012 Unintentional Poisoning* Related ED Visits (2009-2012) ED visit rates/100,000 pop. NC state average ED visit rate=743.8 visits 1000 900 800 700 600 500 400 300 200 100 0 899.3 825.1 812.2 722.3 618.8 598.8 Cabarrus Rowan Stanly 2009 2012 *Sources: NCDETECT for ED and NCSCHS for Hospitalizations, based on ICD-9-CM codes=292.0, 960-969.9, 977.9, E850-E858.9, 960-969.9, E980-E980.9, 304-304.9, 305.2-305.93, Records must NOT also have one of the following E-codes: between 'E950' and 'E959.99. Report prepared by K. Harmon, NC-DPH Injury and Violence Prevention Branch, Jan. 2011. 7

Hospitalization Rates: Cabarrus, Rowan, Stanly (2008) 900 Hospitalization rates/100,000 pop. NC state average hospitalization rate=433.6 hospitalizations 800 700 600 613.2 500 400 469.3 440.8 300 200 100 0 Cabarrus Rowan Stanly *Sources: NCDETECT for ED and NCSCHS for Hospitalizations, based on ICD-9-CM codes=292.0, 960-969.9, 977.9, E850-E858.9, 960-969.9, E980-E980.9, 304-304.9, 305.2-305.93, Records must NOT also have one of the following E-codes: between 'E950' and 'E959.99. Report prepared by K. Harmon, NC-DPH Injury and Violence Prevention Branch, Jan. 2011. 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 Source: NC CSRS Project Lazarus Model The Wheel Addiction Treatment Harm Reduction Pain Patient Support Community Education Public Awareness Coalition Action Data & Evaluation Diversion Control Provider Education Hospital ED Policies The Project Lazarus model can be conceptualized as a wheel, with three core components (The Hub) that must always be present, and seven components (The Wheel) which can be initiated based on specific needs of a community. 8

The SPOKES Community Education - efforts are those offered to the general public and are aimed at changing the perception and behaviors around sharing prescription medications, and improving safety behaviors around their use, storage, and disposal. Prescription medication: take correctly, store securely, dispose properly and never share. COMMUNITY Medical Tribal Faith Family Peers Civic Youth Senior Services ENVIRONMENTAL SITUATION Individual Biological Psychological Social Spiritual Law Enforcement Local Gov t/health Schools Military Treatment Human Service Media Courts Venues to help build coalitions 9

Relational Diagram among All Components of the Coalition Building Capacity School-based education must be age-appropriate and go beyond just say no. 10

Cabarrus Schools Data Sources 2009 Youth Risk Behavior Survey (YRBS) Surveyed approximately 5% of all Cabarrus County high school students Included questions related to alcohol and drug use, bullying, violence-related behaviors, mental health, and sexual behavior 2014 Student Survey Surveyed approximately 5% of all Cabarrus County middle and high school students Included questions on alcohol and drug use from 2009 YRBS as well as additional perception questions 2014 Teen Task Force Survey Surveyed Teen Task Force members in 11 th and 12 th grade Questions focused on student perceptions of alcohol and drug use Lifetime Use of Alcohol, Tobacco, and Other Drugs 2009 YRBS 80 70 71.8 60 51.6 50 40 41 44.4 30 25.8 25.2 23.7 20 14.8 10 0 Alcohol Cigarettes Marijuana Rx Drugs (no doctor s order) 9th Grade 12th Grade During the past 30 days, on how many days did you have at least one drink of alcohol? 25 2014 Student Survey 20 19.3 15 10 7.4 5 1.7 4.7 2.9 3.3 4 0 1-2 Days 3-5 Days 6-9 Days 10+ Days 0 9th 12th 11

During the past 30 days, how many times did you use marijuana? 12 10 2014 Student Survey 10.7 8 6.7 6 4 2.9 2.9 3.3 4 2 0 1-2 Times 3-9 Times 10+ Times 9th 12th During your life, how many times have you taken a prescription drug (such as OxyContin, Hydrocodone, Percocet, Vicodin, Adderall, Ritalin, Valium, or Xanax) without a doctor s prescription? 2014 Student Survey 6 5 4 3 2 1 0 1-2 Times 3-9 Times 10+ Times 9th 12th 12

Patient opioid safety education starts in the clinic and continues in the community. The Spokes- Prescriber Education Treatment of chronic pain Exploring options instead/in addition to medications Reduce risk of patient medication diversion Reduce risk of patient overdose Reached via trainings with Continuing Medical Education Units (CME), lunch and learn, Grand Rounds, webinars Use of the Prescribers Toolkit http://www.ccwjc.com/forms/chronic%20pain/pcp %20Toolkit.pdf 13

THE SPOKES cont. Hospital ED Prescribing Hospital Emergency Department (ED) Policies - it is recommended that hospital EDs develop a system-wide standardization with respect to prescribing narcotic analgesics as described in the Project Lazarus/Community Care of NC Emergency Department Toolkit for managing chronic pain patients: 1) Embedded ED Case Manager 2) Frequent fliers for chronic pain, non-narcotic medication and referral 3) No refills of controlled substances 4) Mandatory use of PDMP 5) Limited dosing (10 tablets) THE SPOKES cont. Diversion Control Diversion Control - Supporting patients who have pain, particularly those who are treated with opioid analgesics, is an important form of diversion control: take correctly, store securely, dispose properly and never share. - Law Enforcement, Pharmacist and Facility training on forgery, methods of diversion and drug seeking behavior THE SPOKES cont. Pain Patient Support Pain Patient Support - In the same way that prescribers benefit from additional education on managing chronic pain, the complexity of living with chronic pain makes supporting community members with pain important. Proper medication use and alternatives Take correctly, store securely, dispose properly and never share! 14

The Spokes- Harm Reduction Overdose prevention training Increasing access to naloxone (Narcan) Reverse opioid overdose Prescribetoprevent.org Distributing a script that gives patients specific language they can use with their family to talk about overdose and develop an action plan, similar to a fire evacuation plan Naloxone access to community in general and military Operation OpioidSAFE Cabarrus EMS naloxone rescue Naloxone: A drug used to counter the effects of opiate overdose 112 EMS staff are currently trained to use Naloxone EMS has used Naloxone 231 times in the past year EMS has responded to 369 calls related to prescription and illicit drugs in the past year. Project Lazarus Model Addiction Treatment Community Education Provider Education Harm Reduction Pain Patient Support NALOXONE Diversion Control Hospital ED Policies The Project Lazarus model can be conceptualized as a wheel, with three core components (The Hub) that must always be present, and seven components (The Wheel) which can be initiated based on specific needs of a community. 15

Drug treatment and Recovery Addiction treatment, especially opioid agonist therapy like methadone maintenance treatment or office based buprenorphine treatment, has been shown to dramatically reduce overdose risk. Unfortunately, access to treatment is limited by two main factors: Availability and accessibility of treatment options, Negative attitudes or stigma associated with addiction in general and drug treatment. Lazarus Recovery Services Overdose Survivors Group Family Addiction Support Family Peer Specialist Support Housing Family Overdose Support Biological Psychological Parent/ Family Empowerment Faith Individual Medical Addiction Support Group Social Spiritual Harm Reduction Nutrition/Wellness Community Life Skills Support Adolescent Support 16

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 (but this could be due to random chance) In counties with coalitions 1.7% more residents received opioids than in counties without a coalition. 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. For every unit increase in county leadership there is a 2.7-fold increase in the odds of having community forums & workshops, after accounting for other prevention efforts and resources. Level 3: "People have talked about doing something, but so far there isn t anyone who has really taken charge. There may be a few concerned people, but they are not influential. Wilkes County NC RESULTS www.projectlazarus.org Fred Wells Brason II 50 The overdose death rate dropped 69% in two years after the start of Project Lazarus and the Chronic Pain Initiative. Wilkes County Results Operation OpioidSafe, US Army Ft. Bragg, NC 15 OD s per 400 soldiers to 1 per 400. Wilkes Scripts related to overdose 2008 82%, 2011 0% School based SA incidences 7.3 per 1000 2011-2012 to 4.9 2012-2013 SA ED visits down 15.3 % Prescribing levels relatively the same OTP SA treatment admissions 2010-0, 2013-400+ Involuntary commitments reduced/less SA calls Churches providing fundraisers for treatment Diversion Tips increased 17

Wilkes County had higher than state average opioid dispensing during the implementation of Project Lazarus and the Chronic Pain Initiative. Access to prescription opioids was not dramatically decreased. Source: NC CSRS Wilkes County Overdose Script History In 2011, not a single OD decedent had an opioid prescription from a Wilkes County prescriber. The fundamental risk:benefit ratio for opioids can be altered for the better through a community-wide approach. NC Statewide Collaborative MAHEC - Kate B. Reynolds Charitable Trust - Office of Rural Health Community Care NC Project Lazarus Governors Institute for SA UNC Injury and Prevention Research Center NC Medical Board/NC Medical Society/NC Hospital Association NC College of Emergency Physicians/Family Practice/Physicians Assistants NC Div. MHDDSAS/OTP s/pdmp SBI/NC Sheriffs Association Carolinas Poison Center Dental Society FQHC Prevention Organizations Coalitions 18

Project Lazarus deliverables I. Training and Technical Assistance A. Leadership Training Manual B. Community Toolkit 1. Sector Fact Sheets/Sector Training 2. Media 3. Sustainability II. Pharmacist CE III. Law Enforcement Training Project Pill Drop IV. School Resource Personnel CE V. Prescriber CME A. Prescribers Toolkit B. ED Toolkit VI. Naloxone Project Lazarus initiative Rescue Kits VII. Data and Evaluation VIII. Community Based Addiction/Recovery Support Services projectlazarus.org communitycarenc.org Dr. Mike Lancaster mlancaster@n3cn.org Fred Wells Brason II FWBrason2@projectlazarus.org Robert Wood Johnson Community Health Leader Award 2012 Casey Reeves Feb. 4, 1980 August 12, 2006 19