Project Lazarus A community-wide response to managing pain

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)

Key program components: What is the Chronic Pain Initiative? 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 Focus Primary Care Physician Toolkit Take only your own medications Emergency Department Toolkit Keep medications in a safe place Care Management Toolkit Education on dangers of opioids Network CPI Champion Model is based on proper assessment, diagnosis, and treatment plan with Pain agreement as necessary

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 1999 - 2001 Source: N.C. State Center for Health Statistics, Vital Statistics-Deaths, 1999-2009 Analysis by Injury Epemiology and Surveillance Unit

Unintentional Poisoning Deaths by County: N.C., 1999-2009 2002 - 2005 Source: N.C. State Center for Health Statistics, Vital Statistics-Deaths, 1999-2009 Analysis by Injury Epemiology and Surveillance Unit

Unintentional Poisoning Deaths by County: N.C., 1999-2009 2006 - 2009 Source: N.C. State Center for Health Statistics, Vital Statistics-Deaths, 1999-2009 Analysis by Injury Epemiology and Surveillance Unit

Mortality rate/100,000 population Poisonings on the Rise NC mortality rates, unintentional and undetermined intent poisonings, 2001-2010 Mortality rate/100,000 population *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.

Problem Acute in Wilkes County Unintentional and undetermined intent poisoning mortality rates Wilkes County, NC 2003-2009 Mortality rate/100,000 population 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. Source: NC SCHS, August 2009

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): $98,986,010 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, 1/19/2011 According to the data Katie Harmon prepared for me on Jan 19, 2011, there were 5,833 hospitalizations in NC in 2008 (the most recent year for which hospital data are available) for ICD-9-CM codes that identify the drug-specific DX codes for poisonings (960-960.9 codes), undetermined poisonings and unintentional poisonings . The AHRQ costs for poisoning hospitalizations in NC for 2008 were $16,970. Multiplying 5,833 x 16,970 = 98,986,010. In 2008, there were 40,093 hospitalizations for a combination of mutually exclusive set of codes for Substance Abuse + Dx for poisonings (the 960-960.9 codes) + Undetermined poisonings + Unintentional poisonings. We don’t have the Healthcare Research and Quality codes for substance abuse hospitalizations, so I don’t think it would be correct to multiply the full 40,903 hospitalizations by the cost figure of $16,970.

Medicaid Network Patient Case Management 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

Controlled Substances/Overdoses

Opioids a Rising NC Problem Narcotics causing or contributing to fatal unintentional and undetermined intent poisonings*: N.C. residents, 2001-2010 t *Source: NC State Center for Health Statistics; annually generated poisoning report for Project Lazarus

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)

Key Ingredients in Chronic Pain Initiative 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

Contents of the Toolkit General information Managing chronic pain Proper prescription writing Precautions Tools for managing chronic pain patients Universal Precaution for Prescribing and Algorithm for assessing and managing pain Pain Treatment Agreement Format for progress notes Medication flowsheet Personal care plan Prescriber and Patient education materials Screening Forms and Brief Intervention Naloxone Prescribing Controlled Substance Reporting System (CSRS)

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

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

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

Project Lazarus Results 1. Lower Risk in the Community 2. Similar Benefit to Patients 69% 3. Improved Risk : Benefit 15%  15% 

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)

Contact Dr. Mike Lancaster Fred Wells Brason II mlancaster@n3cn.org Fred Wells Brason II fbrason@projectlazarus.org www.communitycarenc.org