1. Chronic Pain Initiative
CCNC and Project Lazarus:
Chronic Pain and Community Initiative

2. 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)

3. 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

4. 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

6. Unintentional Poisoning Deaths by County: N.C., 1999-2009
Prepared by Project Lazarus with an unrestricted educational grant from Purdue Pharma LP, NED101356
Source: N.C. State Center for Health Statistics, Vital Statistics-Deaths, Analysis by Injury Epemiology and Surveillance Unit
2/24/2019

7. Unintentional Poisoning Deaths by County: N.C., 1999-2009
Prepared by Project Lazarus with an unrestricted educational grant from Purdue Pharma LP, NED101356
Source: N.C. State Center for Health Statistics, Vital Statistics-Deaths, Analysis by Injury Epemiology and Surveillance Unit
2/24/2019

8. Unintentional Poisoning Deaths by County: N.C., 1999-2009
Prepared by Project Lazarus with an unrestricted educational grant from Purdue Pharma LP, NED101356
Source: N.C. State Center for Health Statistics, Vital Statistics-Deaths, Analysis by Injury Epemiology and Surveillance Unit
2/24/2019

9. Unintentional & undetermined intent poisoning mortality rates by year: U.S. and N.C., 2003-2010*
Project Lazarus creates for each of the communities it works in a profile of deaths, ED visits, and hospitalizations resulting from the misuse and abuse of prescription drugs and other substances and a profile of outpatient dispensed prescriptions for controlled substances.
This is one of the most dramatic graphs that we have shown in Wilkes. It clearly illustrates that the county’s death rate from prescription drugs for the past decade has been about four times higher than the rate for the state or the nation.
Since 2010, there has been a dramatic decline in the mortality rate from unintentional overdoses with a 40% reduction in the rate of unintentional poisoning deaths between 2009 and 2010 and an additional 40% decline from 2010 to 2011.
*Sources: NC SCHS; CDC
2/24/2019

10. Increase in Opioid Prescribing in North Carolina
*Source: NC CSRS

11. Doctor Shopping Decreases in North Carolina Since CSRS
*Source NC CSRS

12. Unintentional & undetermined intent poisoning mortality rates by year: NC and Wilkes Co., N.C., *
Project Lazarus creates for each of the communities it works in a profile of deaths, ED visits, and hospitalizations resulting from the misuse and abuse of prescription drugs and other substances and a profile of outpatient dispensed prescriptions for controlled substances.
This is one of the most dramatic graphs that we have shown in Wilkes. It clearly illustrates that the county’s death rate from prescription drugs for the past decade has been about four times higher than the rate for the state or the nation.
Since 2010, there has been a dramatic decline in the mortality rate from unintentional overdoses with a 40% reduction in the rate of unintentional poisoning deaths between 2009 and 2010 and an additional 40% decline from 2010 to 2011.
*Sources: Wilkes County Health Dept.; NCHS; CDC
2/24/2019

13. Fatal poisonings by intent: North Carolina, 2010*
*Source: NC State Center for Health Statistics Annual All Poisonings Report , October 2011
2/24/2019

14. 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, 01_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 ( 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 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.
Prepared by Project Lazarus through an unrestricted educational grant from Purdue Pharma LP: NED101356

15. Controlled Substances/Overdoses

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

17. 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)

18. 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

19. 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)

20. 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

21. 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

22. 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

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

24. Urban areas may have access to (pain) care issue
*Source NC CSRS

25. 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)
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 at the same time.
More professional coalitions may have a greater impact on reducing Rx drug harms.
Data Sources: NC Health Directors Survey, NC DETECT (2010), CSRS ( )

26. 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

27. AccessCare Network Sites Community Care Plan of Eastern Carolina
Cherokee
Graham
Swain
Clay
Macon
Jackson
Haywood
Transylvania
Madison
Buncombe
Henderson
Yancey
McDowell
Rutherford
Polk
Avery
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
Mitchell
Alamance
Durham
Granville
New
Hanover
Chowan
Perquimans a
Camden r
Currituck
Pasquatank
Legend
AccessCare Network Sites Community Care Plan of Eastern Carolina
AccessCare Network Counties Community Health Partners
Community Care of Western North Carolina Northern Piedmont Community Care
Community Care of the Lower Cape Fear Northwest Community Care
Carolina Collaborative Community Care Partnership for Health Management
Community Care of Wake and Johnston Counties Community Care of the Sandhills
Community Care Partners of Greater Mecklenburg Community Care of Southern Piedmont
Carolina Community Health Partnership
Source: CCNC 2011

28. Contact Dr. Mike Lancaster Fred Wells Brason II
Fred Wells Brason II